Mind-body practices, interoception and pain: a scoping review of behavioral and neural correlates

Figures & data

Table 1. Inclusion and exclusion criteria.

General criteria
Inclusion	Exclusion
English	Non-English
Peer Reviewed Articles Published in a peer reviewed journal	Non-peer reviewed. Dissertations/theses, poster/oral presentations, white papers, book chapters
Original Quantitative Empirical Studies Randomized Controlled, Non-Randomized, Crossover, Longitudinal, Cross-sectional	Non-empirical, Review or Qualitative Literature Review, Narrative Review, Hypothesis and Theory articles, Systematic Reviews, Meta-analyses, Case Studies (N < 5)
Interoception Outcomes, at least one: Behavioral: MAIA, BRQ, BAQ, heartbeat tracking or detection tasks. Neural Correlates: somatosensory, somatomotor cortices, insular cortex, anterior cingulate cortex, ventromedial and dorsolateral prefrontal cortices.	No Interoception Outcome as defined. If included only for a neural correlate, excluded if no pain-related outcome (e.g. working memory in chronic pain).
Type of Mind-Body Practice Any type of yoga, mindfulness, meditation, tai chi, or qigong.	Any other type of Mind-Body Practice e.g. Feldenkrais, Basic Body Awareness Therapy, Psychotherapies without a mindfulness-based component (CBT, ACT), MBP combined with another intervention (e.g. tDCS).
Criteria specific to mind-body practices for chronic pain
Chronic Pain Population Any type of pain lasting ≥ 3 months (If duration unreported, met by reported diagnostic criteria that includes minimum 3 months pain duration (e.g. fibromyalgia or cLBP))	Non-Chronic Pain Population Healthy participants, clinical conditions with unreported chronic pain (e.g. Cancer, PTSD), or pain duration < 3 months (If duration unreported, reported diagnostic criteria that did not include 3 months duration (e.g. some findings in knee osteoarthritis)
Criteria specific to pain-evoked tasks in mind-body practitioners
Experienced Practitioners As defined by the original authors.	Non-experienced Practitioners Healthy practitioners assigned to an MBP intervention.
Included a pain-evoked task	No pain-evoked task

Italics indicate additional criteria added after initial abstract/title screening to limit the scope of the review for more meaningful analysis. MBP: mind-body practice; MAIA: Multidimensional Assessment of Interoceptive Awareness; BAQ: Body Awareness Questionnaire; BRQ: Body Responsiveness Questionnaire; CBT: Cognitive Behavioral Therapy; ACT: Acceptance and Commitment Therapy; tDCS: transcranial direct current stimulation; cLBP: chronic low back pain; PTSD: post-traumatic stress disorder.

Figure 1. PRISMA flowchart.

Table 2. Study characteristics of Mind-Body practices (MBP) for chronic pain.

Author (year)	Sample size; Population; Pain duration; Mean Age; Female: Male	Practice Type; Control group	Study design; Intervention length	Study Outcomes
Behavioral outcomes
de Jong (2016)	N = 31; chronic pain + comorbid depression Pain duration: > 3 months Age: 49.5 ± 10.6 23F:8M	MBCT; TAU	Pilot RCT; 8 weeks	MAIA, PCS, Quick Inventory of Depressive Symptomatology – Clinician Rated (QIDS-C16)
Lauche (2016)	N = 114; chronic neck pain Pain duration: > 3 months Age: 49.4 ± 11.7 91F:23M	Tai Chi; Neck Exercises; Wait-list control	RCT; 12 weeks	MAIA, VAS-Pain intensity, VAS-Pain on Movement (POM), PSS, HADS, Neck Disability Index (NDI), SF-36 Mental & Physical Health indices, Questionnaire on the Assessment of Physical Wellbeing, Postural Awareness Scale (PAS)
Lauche (2017)	N = 75; chronic neck pain Pain duration: > 3 months Age: 49.5 ± 11.6 59F:16M	Tai Chi; Neck Exercises	Secondary analysis of parent RCT [24]; 12 weeks	MAIA, VAS-Pain intensity, PSS, HADS, Postural Awareness Scale (PAS)
Osypiuk (2020)	N = 21; breast cancer survivors with persistent post-surgical pain Pain duration: >3 months Age: 54 ± 10.2 21 F:0M	Multimodal Qigong Mind-Body Exercise (QMBE); no control	Longitudinal pilot study; 12 weeks	MAIA, BPI, HADS, PSS, PCS, Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Rosenberg Self Esteem Scale (RSE), Godin Leisure Time Exercise Questionnaire (GLTQ), Self-Efficacy for Exercise Scale (SEES), Functional Assessment of Cancer Therapy Breast Symptom Index (FACT-B + 4), Grip strength, Shoulder ROM
Roberts (2021)	N = 95; opioid-treated chronic pain Pain duration: 201.5 ± 139.4 months Age: 56.8 ± 11.7 63 F:32M	Mindfulness-Oriented Recovery Enhancement (MORE); Support group psychotherapy	Secondary analysis of parent RCT [25]; 8 weeks	MAIA, Emotion Regulation Questionnaire (ERQ), Depression Anxiety Stress Scale (DASS)
Schmid (2019)	N = 67; heterogenous chronic pain Pain duration: > 6 months Age: 50.78 ± 10.43 46F:21M	Hatha Yoga; Usual care	Pilot RCT; 8 weeks	BRQ, BPI, Rand 36-item Health Survey, Chronic Pain Self-Efficacy Scale (CPSS), Stanford Self-Efficacy for Managing Chronic Disease (SSMCD-6)
Sherman (2013)	N = 192; cLBP Pain duration: > 3 months Age: 49 ± 9.3 123 F:69M	Viniyoga; Stretching; Self-care book	Secondary analysis of parent RCT [6]; 12 weeks	8 Questions from BAQ and BRQ combined, RDQ, PSS, TSK, Arthritis Self-Efficacy Scale, SF-36 Mental health index, Positive States of Mind Scale, Sleep Quality – single item from RDQ, hours of back exercise in past week
Neural Correlates
Berry (2020)	N = 20, cLBP Pain duration: 10.66 ± 8.98 years Age: 40.15 ± 12.56 13F:7M	Brief Self-compassion Training; no control	Longitudinal; 8 contact hours over 2 intensive group trainings + 2 weeks home practice	Pain-evoked fMRI MAIA, PCS, RMQ, PROMIS-Intensity, Self-Compassion Scale (SCS)
Braden (2016)	N = 26, cLBP Pain duration: not reported; recruited from spine center where regularly seen by physicians. Age: 44.5 ± 6.9 17F:9M	Abbreviated MBSR; Stress reduction reading	Pilot trial (pseudo-randomized); 4 weeks	Emotion-evoked fMRI BDI-II, STAI – State only, Oswetry Low Back Pain Scale
Brown (2013)	N = 28; chronic musculoskeletal pain (57% fibromyalgia) Pain duration: not reported; diagnostic criteria from medical records. Age: 46.5 ± 11 21 F:7M	Mindfulness Pain Management Program (MBPM); TAU	RCT; 8 weeks	Pain-evoked EEG MPQ-Short form, SF-36 Mental & Physical health indices, Pain Stages of Change Questionnaire, Survey of Pain Attitudes, Mindful Attention and Awareness Scale (MAAS)
Hatchard (2021)	N = 21; breast cancer survivors with chronic neuropathic pain Pain duration: > 6 months Age: 52.4 ± 9.7 21F:0M	MBSR; Waitlist control	Sub-study of larger RCT [26]; 8 weeks	Emotion-evoked fMRI BPI, FFMQ
Hudak (2021)	N = 62; veterans with opioid-treated chronic pain Pain duration: 16.4 ± 12.9 years Age: 59.3 ± 9.9 9F:53M	Mindfulness-Oriented Recovery Enhancement (MORE); Support group psychotherapy	Mechanistic sub-study of larger clinical trial (ongoing); 8 weeks	EEG during meditation Opioid dose, Nondual Awareness Dimensional Assessment (NADA-state), Perceived Body Boundaries Scale (PBBS)
Kong (2019)	N = 41; fibromyalgia Pain duration: not reported, met fibromyalgia diagnostic criteria. Age: 53 ± 11.3 39 F:2M	Tai-chi; Healthy control	Partial Crossover; 12-weeks	Resting state fMRI FIQR, BDI-II
Medina (2022)	N = 46; fibromyalgia Pain duration: > 1 year since fibromyalgia diagnosis. Age: 52.6 ± 8.6 46F:0M	MBSR + TAU; FibroQOL + TAU; TAU control	Sub-study of larger RCT [27]; 8 weeks	ASL, whole brain rCBF maps VAS-Pain intensity, FIQR, HADS, PCS
Seminowicz (2020)	N = 98; migraine Pain duration: ≥ 1 year Median Age: 36 (18–65) 89 F:9M	Enhanced MBSR (MBSR+); Stress Management for Headache	RCT; Weekly for 8 weeks + biweekly for additional 8 weeks (16 weeks total)	Structural MRI, resting state fMRI, task-evoked fMRI Headache frequency and intensity (pain diary), Headache Impact Test (HIT), Response to treatment (≥50% reduction in headache days)
Shen (2021)	N = 12; postmenopausal women with knee osteoarthritis (KOA) Pain duration: not reported, met by diagnostic criteria Age: 64.5 ± 6.7 12 F:0M	Tai Chi; no control	Exploratory pilot study; 8 weeks	Structural MRI, resting state fMRI, diffusion tensor imaging (DTI) VAS-Pain intensity, BPI, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)

N: number included in analyses. Bold text represents interoception outcomes. Commonly used abbreviations are as follows: ASL: Arterial Spin Labelling; BAQ: Body Awareness Questionnaire; BDI-II: Beck’s Depression Inventory; BPI: Brief Pain Inventory; BRQ: Body Responsiveness Questionnaire; cLBP: chronic low back pain; EEG: Electroencephalography; FFMQ: Five Facet Mindfulness Questionnaire; FIQR: Revised Fibromyalgia Impact Questionnaire; (f)MRI: (functional) magnetic resonance imaging; HADS: Hospital Anxiety and Depression Scale; MAIA: Multidimensional Assessment of Interoceptive Awareness; MBCT: Mindfulness Based Cognitive Therapy; MBSR: Mindfulness Based Stress Reduction; MPQ: McGill Pain Questionnaire; PCS: Pain Catastrophizing Scale; PROMIS: Patient Reported Outcomes Measurement Information System; PSS: Perceived Stress Scale; rCBF: regional Cerebral Blood Flow; RCT: Randomized Controlled Trial; RMQ/RDQ: Roland-Morris Low Back Pain and Disability Scale; ROM: Range of Motion; SF-36: Short Form 36 Item; STAI: State Trait Anxiety Inventory; TAU: Treatment as Usual; TSK: Tampa Scale for Kinesiophobia; VAS: Visual Analog Scale.

Table 3. Effects of Mind-Body Practices (MBP) on interoceptive outcomes in chronic pain.

Author (year)	Key findings
Behavioral Outcomes
de Jong (2016)	Mindfulness-Based Cognitive Therapy (MBCT) vs. Treatment as Usual (TAU) in chronic pain with comorbid depression. Pre-training: MAIA-ND did not correlate with other MAIA subscales. Distraction from pain coping style may be distinct from other aspects of body awareness in chronic pain. Post-training: MBCT vs. TAU: ↑MAIA-SR; ↑MAIA-ND partially mediated ↓depression; No effect on MAIA-N, MAIA-AR MBCT improved self-regulatory capacity and may enhance ability to turn towards, rather than away from pain. Learning coping styles in contrast to distraction/avoidance may be an important predictor of mental health outcomes in chronic pain. MBCT within group: ↑MAIA-EA MBCT improved awareness of connection between body and emotional states.
Lauche (2016)	Tai Chi vs. Neck Exercises vs. Waitlist control in chronic neck pain. Post-training: Tai Chi vs. Waitlist: ↑MAIA (mean), ↓VAS-Pain intensity, ↓Neck Disability (NDI), ↑SF-36, ↓Pain on Movement Tai Chi improved pain intensity, evoked pain on movement, neck-related disability, and quality of life. Interoceptive sensibility demonstrated a mean increase after training. Tai Chi vs. Neck Exercises: No differences between groups. Tai Chi had a comparable effect to neck exercises on interoceptive sensibility and all other outcomes.
Lauche (2017)	Secondary analysis of parent RCT [24]; Examined predictors of reduced pain intensity in Tai Chi vs. Neck Exercises. Regression analysis Tai Chi & Neck Exercises: MAIA (ns), ↑Baseline VAS-Pain intensity, ↓HADS-A, ↑postural awareness predicted 40.6% of variance in reduced pain. Regardless of intervention group, higher baseline pain, anxiety reduction and improved postural awareness, but not interoceptive sensibility, predicted reductions in pain after treatment.
Osypiuk (2020)	Longitudinal Qigong Mind-Body Exercise in breast cancer survivors with persistent post-surgical pain. Post-training: Qigong: ↑MAIA-NW, ↑MAIA-AR, ↑MAIA-EA, ↑MAIA-SR, ↑MAIA-BL, ↑MAIA-TR, MAIA-N (ns), MAIA-ND (ns), ↓BPI-Severity, ↓BPI-Interference, ↑FACIT-F, ↑FACT-B, ↓HADS, ↓PSS, ↓PCS, ↑RSE Qigong improved several clinical outcomes, including pain severity/interference, fatigue, quality of life, mood, stress, pain catastrophizing and self-esteem as well as several domains of interoceptive sensibility except noticing and not distracting.
Sherman (2013)	Secondary analysis of parent RCT [25]; Examined MAIA-SR as a mediator of emotion regulation after Mindfulness-Oriented Recovery Enhancement (MORE) vs. Support Group (SG) Psychotherapy in opioid-treated chronic pain. Post-training: MORE vs. SG: ↑MAIA-total, ↑MAIA-SR, ↑ERQ, ↓DASS. MORE had a greater effect on improving overall interoceptive sensibility, interoceptive self-regulation, cognitive reappraisal, and emotional distress than psychotherapy. Mediation analysis: MORE vs. SG: ↑MAIA-SR mediated ↑ERQ; ↑ERQ mediated ↓DASS. MORE facilitated reductions in emotional distress by improving cognitive reappraisal via enhanced interoceptive self-regulation.
Schmid (2019)	Hatha Yoga vs. Usual Care in heterogenous chronic pain Post-training: Yoga vs. Usual care: ↑BRQ, ↑CPSS (total, physical function, & pain management) Yoga had a greater impact on improving body responsiveness and self-efficacy for pain management than usual care. Yoga within group: ↑BRQ, ↓BPI-Interference, ↑CPSS, ↑SSMCD-6; Both groups: ↑Rand-36 QOL Both groups improved overall quality of life, only yoga also improved pain interference in addition to improved body responsiveness and pain self-efficacy.
Sherman (2013)	Secondary analysis of parent RCT [6]; Examined mediators of improved back function in Yoga vs. Stretching in cLBP. Mediation analysis: Yoga: 61% ↓RDQ explained by: ↑self-efficacy, hours of exercise, ↑BRQ/BAQ, ↑SF-36-MCS, ↓PSS, ↓RDQ-Sleep item Stretching: 50% ↓RDQ explained by: ↑self-efficacy, hours of exercise, ↑BRQ/BAQ, ↑SF-36-MCS, ↓TSK, ↑Positive states of mind Self-efficacy and hours of exercise most significantly mediated improved back function in both groups. Body awareness was not an independent mediator for either group. Qualitative data suggested to reflect distinct mechanisms, including greater relaxation/awareness in yoga and greater discipline/routine in stretching.
Neural correlates
Berry (2020)	Longitudinal Brief Self-Compassion training in cLBP; Pain-evoked fMRI in a self-compassionate state. Post-training, neural correlates: During pain: ↓R TPJ ∼↓PROMIS-Pain intensity Suggested to reflect enhanced present-moment awareness during pain, correlating with reduced pain intensity. During pain anticipation: ↑vPCC ∼↑MAIA-BL; ↑R dlPFC ∼↓SCS (Self-Compassion Scale) Interpreted as less prefrontal recruitment, reflecting more efficient use of self-compassion resources, and increased awareness of body ownership and internal sensations. Post-training, behavioral outcomes: During pain: VAS-Pain intensity (ns), VAS-Pain unpleasantness (ns) Self-Compassion training: ↑MAIA-total, ↑MAIA-AR, ↑MAIA-SR, ↑MAIA-BL, remaining MAIA subscales all (ns); ↑SCS ∼ ↑daily practice; ↓PROMIS-Intensity, ↓RMQ. Increased self-compassion after training associated with amount of daily practice. Self-compassion training improved pain intensity, disability, and several domains of interoceptive sensibility, despite no difference in evoked pain ratings.
Braden (2016)	Abbreviated MBSR vs. Stress Reduction Reading (RCon) in cLBP; Emotion-evoked fMRI Post-training, neural correlates: During sadness-induction task, MBSR vs. RCon: ↑sgACC∼↑sad valence ratings; ↑L vlPFC, ↑dmPFC (trend), ↑R vlPFC (trend) Interpreted to reflect increased conscious access to emotional state, corresponding with emotional intensity ratings, and greater prefrontal activity interpreted as increased attentional awareness of emotional state. Post-training, behavioral outcomes: During sadness-induction task: VAS-arousal (ns), VAS-valence (ns) MBSR: ↓BDI-II (somatic-affective), ↓ODI; Stress-Reduction: ↓BDI (cognitive); Both groups: ↓BDI, State Trait Anxiety (STAI) (ns) Abbreviated MBSR uniquely improved back pain symptoms and somatic-affective component of depression, whereas both groups improved in overall depression with no change in anxiety or evoked emotional arousal or valence ratings.
Brown and Jones (2013)	Mindfulness-Based Pain Management (MBPM) vs. Treatment as Usual (TAU) in chronic musculoskeletal pain; Pain-evoked EEG Post-training, neural correlates: During pain, MBPM vs. TAU: ↓aINS (ns), ↓amygdala (ns) Interpreted as mildly reduced emotional processing during pain. During pain anticipation, MBPM vs. TAU: ↓dlPFC & ↓S2 deactivation (i.e. ↑activity) ∼ ↑Mental health & ↑Pain controllability Interpreted as greater cognitive control and focus on body sensations, rather than distraction during pain anticipation, correlated with improved mental health and perceived control of pain. Post-training, behavioral outcomes: During pain: VAS-Pain unpleasantness (ns) MBPM vs. TAU: ↑Engagement & ↑Pain controllability predicted ↑SF12-MCS; ↑MAAS, MPQ (ns) No change in evoked pain ratings or the sensory/affective components of pain. MBPM improved mental health and mindfulness. Suggested that perceived pain control may have a greater impact on mental health outcomes than the sensory pain experience.
Hatchard (2021)	MBSR vs. Waitlist in breast cancer survivors with chronic neuropathic pain; Emotion-evoked fMRI Post-training, neural correlates: During emotional Stroop task, MBSR vs. Waitlist: ↓S1, ↓dlPFC, ↓precuneus, Interpreted as MBSR reducing activity in regions associated with affective and pain-related words becoming less salient, requiring less executive control over emotions, and less personalized, respectively. Post-training, behavioral outcomes: During emotional Stroop task: Controls ↑reaction time to affective words; MBSR reaction time (ns) Interpreted as increased emotional reactivity over time without intervention. MBSR vs. Waitlist: ↓BPI-Interference, ↑FFMQ, BPI-intensity (ns) MBSR improved pain interference and mindfulness despite no change in pain intensity.
Hudak (2021)	MORE vs. Support Group (SG) Psychotherapy in veterans with opioid-treated chronic pain; Mindfulness-evoked EEG Post-training, neural correlates: MORE vs. SG: ↑frontal theta power mediated ↓opioid dosing, ↑frontal alpha power, ↑Frontal-Midline Theta (FMT) coherence. Interpreted to reflect increased prefrontal activation after MORE, and mindfulness-induced endogenous theta stimulation to PFC improved self-regulation of pain symptoms (i.e. reduce need for opioids). Increased FMT coherence interpreted to reflect enhanced PFC-ACC connectivity, such that mindfulness may facilitate plasticity between top-down and bottom-up self-regulation structures. Post-training, behavioral outcomes: MORE vs. SG: ↓opioid dose, ↑self-referential processing Mindfulness facilitated reduction in opioid craving and changes in self-referential processing associated with ego-dissolution and sense of oneness between self and world. Suggested that mindfulness shifted valuation from drug-related rewards to internal rewards.
Kong (2019)	Tai Chi vs. No Control in Fibromyalgia; Fibromyalgia vs. Healthy control at baseline; resting state fMRI Baseline: Fibromyalgia vs. healthy controls: ↑dlPFC-rACC/mPFC connectivity Fibromyalgia demonstrated altered connectivity, suggested to reflect self-regulatory mechanisms to cope with repeated pain. Post-training, neural correlates: Tai Chi: ↑dlPFC to rACC/mPFC connectivity ∼ ↓FIQR Tai chi further enhanced the altered connectivity in fibromyalgia, associated with clinical improvements, suggested to reflect allostasis such that tai chi further promotes self-regulation to pain. Tai Chi: ↓rACC/mPFC connectivity to periaqueductal gray & hippocampus & ↑rACC/mPFC connectivity with postcentral gyrus/operculum, mid/inferior prefrontal gyrus, and MCC Tai Chi reduced connectivity of rACC/mPFC to regions associated with pain as a form of long-term learning [23] and enhanced connectivity to regions associated with the sensory, cognitive, and emotional aspects of pain. Post-training, behavioral outcomes: Tai Chi: ↓FIQR, ↓BDI-II Tai chi improved fibromyalgia and depression symptoms.
Medina (2022)	MBSR vs. Psychoeducation (FibroQOL) vs. TAU in Fibromyalgia; Arterial Spin Labelling fMRI Baseline: All groups: ↑VAS-Pain intensity predicted ↑ACC and ↑aINS rCBF; ↑amygdala rCBF ∼ ↑HADS-A, ↑PCS, not VAS-Pain intensity At baseline, regions associated with emotional processing of pain correlated with greater pain symptoms. Increased amygdala rCBF correlated with negative emotional symptoms but not pain. Post-training, neural correlates: MBSR & FibroQOL: rCBF to ACC & aINS no longer correlated with VAS-Pain intensity; FibroQOL: ↓amygdala, no longer correlated with HADS-A and PCS. Reduction in blood perfusion after training to emotional processing regions suggested to reflect disruption in pain-related processing, and reorganization of salience and pain networks. Post-training, behavioral outcomes: MBSR: ↓PCS – magnification (did not survive correction); FibroQOL: ↓PCS – rumination, helplessness; Controls: ↓VAS-Pain intensity; All groups: HADS (ns), FIQR (ns). FibroQOL may have a greater impact on appraisal processes related to pain catastrophizing. No effect on symptoms of anxiety, depression, or functional impact in either group. Controls reduced pain intensity, potentially reflecting regression to the mean.
Seminowicz (2020)	Enhanced MBSR (MBSR+) vs. Stress Management for Headache (SMH) in migraine; Structural MRI, resting state & cognitive task fMRI Post-training, neural correlates: Both groups: ↓aMCC GMV, ↓aINS connectivity to cognitive task network MBSR + vs. SMH: ↓aINS connectivity to PPC & cuneus; During cognitive task: ↓cuneus & ↓parietal operculum (including pINS) Decreased aINS connectivity to key regions of the cognitive task network interpreted as increased cognitive efficiency after MBSR+, or less depletion of cognitive and emotional resources during pain. Decreased pINS activity during cognitive task interpreted as increased cognitive efficiency to direct cognitive resources to task demands, rather than pain regulation. Post-training, behavioral outcomes: MBSR + vs. SMH: ↓headache frequency (pain diary), ↑response to treatment (52% vs 23% in control), ↓HIT, headache intensity (ns) MBSR + reduced headache frequency, headache-related disability and had a greater response to treatment, despite no change in headache intensity ratings.
Shen (2021)	Tai Chi vs. No control in postmenopausal women with knee osteoarthritis; Structural MRI, resting state fMRI, DTI. Post-training, neural correlates: Tai Chi: ↑mPFC (ns) to amygdala connectivity ∼ ↑physical function; ↑mPFC (ns) to amygdala DTI connectivity ∼ ↓stiffness Decreased mPFC-amygdala connectivity previously linked to increased chronic pain symptoms. Moderate, but non-significant increased connectivity after Tai Chi suggested to reflect reversal of chronic pain associated neural changes, associated with improved symptoms. Post-training, behavioral outcomes: Tai Chi: ↓knee pain (VAS, WOMAC and BPI), ↓WOMAC-stiffness, ↑WOMAC-physical function Tai chi improved pain and stiffness symptoms and improved physical function.

Bold text represents interoceptive outcomes examined in this review. Italicized text represents author interpretations of key findings. Abbreviations: 1) Methodological abbreviations: (ns): non-significant; (∼): correlates with; cLBP: chronic low back pain; DTI: diffusor tensor imaging; EEG: electroencephalography; (f)MRI: (functional) Magnetic Resonance Imaging; GMV: gray matter volume; rCBF: regional cerebral blood flow; RCT: Randomized Controlled Trial. 2) Neural regions: aINS/pINS: anterior/posterior insula; aMCC: anterior midcingulate cortex; dlPFC/vlPFC/dmPFC: dorsolateral/ventrolateral/dorsomedial prefrontal cortices; PPC: posterior parietal cortex; S1/S2: primary/secondary somatosensory cortices; sgACC/rACC: subgenual/rostral anterior cingulate cortices; TPJ: temporo-parietal junction; vPCC: ventral posterior cingulate cortex; FMT: frontal-midline-theta coherence. 3) Questionnaires: BAQ/BRQ: Body Awareness/Responsiveness Questionnaires; BDI: Beck’s Depression Inventory; CPSS: Chronic Pain Self-Efficacy Scale; FACIT-F: Functional Assessment of Chronic Illness Therapy-Fatigue; FACT-B: Functional Assessment of Cancer Therapy Breast Symptom Index; FFMQ: Five Facet Mindfulness Questionnaire; FIQR: Revised Fibromyalgia Impact Questionnaire; HADS: Hospital Anxiety and Depression Scale; HIT: Headache Impact Test; MAAS: Mindful Attention and Awareness Scale; MAIA: Multidimensional Assessment of Interoceptive Awareness; MAIA-N: Noticing; MAIA-ND: Not Distracting; MAIA-NW: Not Worrying; MAIA-AR: Attention Regulation; MAIA-EA: Emotional Awareness; MAIA-SR: Self-Regulation; MAIA-BL: Body Listening; MAIA-TR: Trusting; MPQ: McGill Pain Questionnaire; PCS: Pain Catastrophizing Scale; PSS: Perceived Stress Scale; Rand-36: Rand-36 Measure of Health Related Quality of Life; RMQ/RDQ: Roland-Morris Low Back Pain and Disability Scale; RSE: Rosenberg Self Esteem Scale; SF-36 (MCS): Short Form 26 (Mental Component Score); SSMCD-6 = Stanford Self-Efficacy for Managing Chronic Disease; TSK: Tampa Scale for Kinesiophobia; VAS: Visual Analog Scale; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index.

Table 4. Study characteristics of interoception outcomes in experienced mind-body practitioners.

Author (year)	Sample size; Experience; Age; Female: Male	Practice Type; Control group	Study design; Pain Stimulus	Study Outcomes
Behavioral outcomes
Zorn (2021)	N = 70 (Practitioners N = 27) Experience: > 10,000 h Age: 52.6 ± 7.7 34F:36M	Kagyu or Nyingma schools of Tibetan Buddhism; Novice controls with 2-day training and ∼20 h OM/FA.	Cross-sectional; thermal heat	MAIA, VAS-Pain intensity, VAS-Pain unpleasantness, PCS, FFMQ, BDI, STAI, Drexel Defusion Scale (DDS), Cognitive Fusion Questionnaire (CFQ), Penn State Worry Questionnaire (PSWQ)
Neural correlates
Brown and Jones (2010)	N = 27 (Practitioners N = 12) Experience: 39-1820 weeks Age: 34 ± 14 13 F:14M	Any form of formal meditation practice; Naïve controls	Cross-sectional; laser stimuli	Pain-evoked EEG VAS-Pain unpleasantness
Gard (2012)	N = 34 (Practitioners N = 17) Experience: 10.2 ± 6.6 years Age: 37.1 ± 7.8 8F:26M	Vipassana meditation; Naïve controls	Cross-sectional; transcutaneous electrical stimuli	Pain-evoked fMRI VAS-Pain intensity, VAS-Pain unpleasantness, VAS-Anticipatory anxiety
Grant (2010)	N = 39 (Practitioners N = 19) Experience: 14.4 ± 8.4 years Age: 37.6 ± 10.7 9F:30M	Zen meditation; Naïve controls	Cross-sectional; thermal heat	Structural MRI Pain sensitivity (temperature to report moderate pain)
Grant (2011)	N = 26 (Practitioners N = 13) Experience: >1000 h Age: 38.2 8 F:18M	Zen meditation; Naïve controls	Cross-sectional; thermal heat	Pain-evoked fMRI VAS-Pain intensity, VAS-Pain unpleasantness
Lutz (2013)	N = 28 (Practitioners N = 14) Experience: > 10,000 h Age: 45.4 ± 10.7 10F:18M	Kagyu or Nyingma schools of Tibetan Buddhism; Novice controls with 7 days x 30-minute OP/FA home practice.	Cross-sectional; thermal heat	Pain-evoked fMRI VAS-Pain intensity, VAS-Pain unpleasantness
Orme-Johnson (2006)	N = 24 (Practitioners N = 12) Experience: 31.3 ± 2.3 years Age: 57 ± 4.6 12 F:12M	Transcendental Meditation; Novice controls with 4-day training and 5 months home practice.	Longitudinal partial crossover; thermal heat	Pain-evoked fMRI VAS-Pain intensity
Villemure (2014)	N = 28 (Practitioners N = 14) Experience: 9.6 ± 2.8 years Age: 36.8 ± 6.9 18F:10M	All types of yoga integrating physical postures, meditation, and breathing exercises; Naïve controls	Cross-sectional; thermal pain threshold, cold pain tolerance	Structural MRI Pain threshold (temperature), Cold pain tolerance (time), VAS-Confidence that yoga improves pain tolerance, Self-reported mental strategies.

N: number included in analyses. Bold text represents interoceptive outcomes included in analyses. Commonly used abbreviations are as follows: BDI: Beck’s Depression Inventory; EEG: Electroencephalography; FA: Focused Attention; FFMQ: Five Facet Mindfulness Questionnaire; (f)MRI: (functional) Magnetic Resonance Imaging; OM: Open Monitoring; OP: Open Presence; MAIA: Multidimensional Assessment of Interoceptive Awareness; PCS: Pain Catastrophizing Scale; STAI: State Trait Anxiety Inventory; VAS: Visual Analog Scale.

Table 5. Pain-related interoception outcomes in experienced mind-body practitioners.

Author (year)	Key findings
Behavioral outcomes
Zorn (2021)	Buddhist Practitioners vs. Novice Controls; Evoked Pain during an Open Presence Meditative State Behavioral outcomes: Practitioners vs. Controls during pain: ↓VAS-Pain unpleasantness, VAS-Pain intensity (ns) Practitioners vs. Controls: ↑MAIA, ↑DDS, ↑FFMQ, ↓PCS, ↓CFQ, ↓PSWQ, ↓STAI, ↓BDI Both groups: ↑DDS & ↓PCS predicted VAS-Pain unpleasantness, not VAS-Pain intensity. ↓PCS ∼ ↑MAIA, ↑DDS, and ↑FFMQ Interoceptive sensibility was not the focus of this analysis, but it was higher in practitioners and negatively correlated with pain catastrophizing across groups. Only cognitive defusion had a higher correlation, and most strongly predicted reduced unpleasantness, suggested to be a core construct in mindfulness-based pain modulation.
Neural correlates
Brown (2010)	Meditation Practitioners (any type) vs. Naïve Controls; Pain-evoked EEG Neural correlates, Practitioners vs. Controls: During pain: ↓S2, ↓INS (did not survive correction for anticipatory activity). During pain anticipation: ↑mPFC/pACC predicted ↓VAS-Pain unpleasantness, mediated by ↓MCC, inverse pattern to controls where ↑mPFC/pACC predicted ↑VAS-Pain unpleasantness. Lifetime experience predicted ↓MCC. Interpreted to reflect reduced negative appraisal of pain, such that increased cognitive control in anticipation of pain reflects greater acceptance of pain, rather than anticipation of threat, contributing to inverse unpleasantness ratings relative to controls. Behavioral outcomes, Practitioners vs. Controls: Pain threshold: (ns) During pain: ↓VAS-Pain unpleasantness (only with 6+ years of experience) ∼ greater experience. Despite no difference in pain threshold, more experienced practitioners demonstrated lower pain unpleasantness ratings.
Gard (2012)	Vipassana (mindfulness) Practitioners vs. Naïve controls; Pain-evoked fMRI while in a mindful state Neural correlates, Practitioners vs. Controls: During pain: ↓bilateral lPFC, ↑pINS/S2 ∼ ↓VAS-Pain unpleasantness During pain anticipation: ↑rACC/vmPFC Interpreted to reflect increased sensory and reduced cognitive processing during pain, and greater attention regulation while anticipating pain. Less unpleasantness correlated with greater sensory pINS/S2 activity in practitioners, but lower activity in controls. Behavioral outcomes, Practitioners vs. Controls: During pain: ↓VAS-Pain unpleasantness (22%), VAS-Pain intensity (ns) During pain anticipation: ↓VAS-anticipatory anxiety (29%) Despite no difference in pain intensity, practitioners reported less unpleasantness and anticipatory anxiety.
Grant (2010)	Zen Practitioners vs. Naïve Controls; Structural MRI and pain-evoked task Neural correlates, Practitioners vs. Controls: Cortical thickness: ↑dACC, ↑S2; ↑Years experience ∼ ↑ACC thickness; ↑Hours experience ∼ ↑S1 thickness Both groups: ↓Pain sensitivity ∼ ↑ACC, ↑S2 and ↑INS thickness Lower pain sensitivity was associated with greater cortical thickness in affective and pain-related regions, with no differences between groups, despite practitioners demonstrating lower pain sensitivity. Authors suggest a more general relationship between cortical thickness and pain, where greater cortical thickness in practitioners may be the result of long-term practice. Behavioral outcomes, Practitioners vs. Controls: Pain Sensitivity: ↓Pain sensitivity Practitioners demonstrated a higher pain threshold than controls.
Grant (2011)	Zen Practitioners vs. Naïve controls; Pain-evoked fMRI, outside a meditative state Neural correlates, Practitioners vs. Controls: During pain: ↑thalamus, ↑ACC and ↑INS activation; ↑hippocampus, ↑amygdala, ↑dlPFC and ↑mPFC deactivation Practitioners: ↓dACC to dlPFC connectivity predicted ↓Pain sensitivity. Interpreted to suggest that practitioners demonstrate a reduction in appraisal/emotion-related regions and greater activation in primary pain processing regions during pain, and less connectivity between cognitive and pain regions. This ‘functional decoupling’ is suggested to allow painful stimuli to be experienced with more acceptance/cognitive disengagement and less threat. Behavioral outcomes, Practitioners vs. Controls: During pain: VAS-Pain intensity (ns), VAS-Pain unpleasantness (ns) Pain Sensitivity: ↓Pain sensitivity Despite no differences in pain intensity and unpleasantness ratings, practitioners had a higher pain threshold.
Lutz (2013)	Buddhist Practitioners vs. Novice Controls; Pain-evoked fMRI while in an Open Presence meditative state Neural correlates, Practitioners vs. Controls: During pain: ↑dorsal aINS/aMCC (salience network), pINS/S2 (ns) Pain anticipation: ↓aINS/aMCC, ↓amygdala Reduced aINS/aMCC activity during pain anticipation and increased aINS/aMCC activity during pain – components of the salience network assigning emotional weight to homeostatically-relevant/interoceptive stimuli [50] – were interpreted to reflect a downregulation of negative anticipatory processing, such that pain is experienced with more acceptance and less unpleasantness. Behavioral outcomes, Practitioners vs. Controls: During pain: ↓VAS-Pain unpleasantness, VAS-Pain intensity (ns) Practitioners reported lower pain unpleasantness despite similar intensity ratings.
Orme-Johnson (2006)	Transcendental Meditation Practitioners vs. Novice controls; Pain-evoked fMRI outside a meditative state Neural correlates, Practitioners vs. Controls: During pain, baseline: ↓whole brain, ↓thalamus activity During pain, after 5 months training for novices: Pain-related activity (ns) between practitioners and controls; Controls ↓thalamus, ↓PFC, ↓whole brain & ↓ACC (ns) activity. Practitioners only demonstrated reduced pain-related activity prior to novices practicing for 5 months, after which there were no longer and significant differences. Behavioral outcomes, Practitioners vs. Controls: During pain: VAS-Pain intensity (ns) There were no differences in pain intensity ratings between practitioners and controls at either time point.
Villemure (2014)	Yoga Practitioners (any type) vs. Naïve controls; Structural MRI and pain tolerance task Neural correlates, Practitioners vs. Controls: GMV: ↑cingulate/SMA/S1, ↑INS/S2, ↑dmPFC; ↑INS GMV ∼ ↑pain tolerance; ↑left INS GMV ∼ ↑years of experience Cortical thickness: ↑cingulate/S1, ↑INS/S2 Yoga practitioners demonstrated increased GMV and cortical thickness in multiple regions, but only insular GMV correlated with greater pain tolerance. As a primary interoceptive region, authors suggest that greater insular GMV may be the result of regular application of interoceptive strategies from long-term yoga practice.. Behavioral outcomes, Practitioners vs. Controls: Pain tolerance task: ↑pain tolerance (2x longer) Pain threshold: (ns) Self-reported mental strategies during pain: Interoceptive/acceptance vs. distraction/avoidance used by controls. Despite similar pain thresholds, practitioners demonstrated greater pain tolerance and reported using interoceptive strategies (e.g. acceptance of sensations, focus on the breath) during pain.

Bold text represents interoceptive outcomes examined in this review. Italicized text represents author interpretations of key findings. Abbreviations: 1) Methodological abbreviations: (ns): non-significant; (∼): correlates with; (f)MRI: (functional) Magnetic Resonance Imaging; EEG: electroencephalography; GMV: gray matter volume; 2) Neural regions:: aINS/pINS: anterior/posterior insula; dlPFC/vlPFC/dmPFC: dorsolateral/ventrolateral/dorsomedial prefrontal cortices; S1/S2: primary/secondary somatosensory cortices; SMA: supplementary motor area; dACC/rACC/pACC: dorsal/rostral/posterior anterior cingulate cortices, aMCC: anterior midcingulate cortex; 3) Questionnaires: BDI: Beck’s Depression Inventory; CFQ: Cognitive Fusion Questionnaire; DDS: Drexel Defusion Scale; FFMQ: Five Facet Mindfulness Questionnaire; MAIA: Multidimensional Assessment of Interoceptive Awareness; PCS: Pain Catastrophizing Questionnaire; PSWQ: Penn State Worry Questionnaire; STAI: State Trait Anxiety Inventory; VAS: Visual Analog Scale.

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Data availability statement

The detailed study protocol is available upon request.