Date of Graduation


Document Type


Degree Type



School of Public Health



Committee Chair

Kim (Karen) Innes

Committee Co-Chair

Peter Giacobbi

Committee Member

Dina Jones

Committee Member

Christa Lilly

Committee Member

Gilbert Ramirez


Introduction: Inflammation is often a component of chronic pain, yet its potential role in fibromyalgia syndrome (FMS) remains inconclusive. FMS is a complex chronic pain condition affecting ~2% of the population; management is challenging and treatment options remain limited. Many herbs contain anti-inflammatory properties, and herbs indicated for analgesia and rheumatic conditions have traditionally been used in Appalachia. Despite the popularity of herbs in the US, determinants and patterns of herbal use with regard to pain management have not been well studied, particularly in Appalachia, where prevalence of chronic pain and related comorbid conditions is high and access to medical care is often reduced. In this series of three studies, we investigate the: 1) relation of FMS to serum C-reactive protein (CRP) in a large Appalachian population; 2) demographic, lifestyle, and health-related correlates of herbs and other complementary health approaches (CHAs) used for pain in a sample of Appalachian chronic pain patients, using a newly developed survey instrument; and, 3) the relation of herbal supplement use to FMS in two nationally representative samples of U.S. adults (NHIS 2007 and 2012), as well as trends in patterns of herbal use over time.;Methods: All participants completed comprehensive health surveys in these three cross-sectional studies. To investigate the relation between diagnosed FMS and serum levels of the proinflammatory marker CRP (Study 1), we used data on 52,535 adult Ohio Valley residents (FMS =1,125), collected in 2005-2006 as part of the C8 Health Project. Medical history, including physician diagnosis of FMS, was ascertained via self-report. To determine the correlates and patterns of herbal and other CHAs used specifically for pain in an Appalachian chronic pain population (Study 2), we collected data on 301 patients from four WV pain and rheumatology clinics using our newly developed survey instrument, the Complementary Health Approaches for Pain Survey (CHAPS) (2014-2016); correlates relating specifically to pain were measured using the Short-Form Global Pain Scale (SF-GPS). To assess the relation of diagnosed FMS to herbal supplement use (at 30 days, past 12 months, and ever) and to examine potential changes in the patterns of use over time (Study 3), we used data from the 2007 and 2012 National Health Interview Surveys (NHIS) (N = 20127 and N = 30672 adults, respectively). Logistic and linear regression (complete-case analysis) were used to examine associations and to evaluate the potential modifying influence of gender and number of health conditions; multivariate models were adjusted for an array of demographic, lifestyle, and health factors. To account for missing data (Study 2), we also conducted additional sensitivity analyses using multiple imputation.;Results: Study 1. In this large Appalachian population, mean serum CRP was significantly higher among participants reporting a diagnosis of FMS than those without FMS (5.54+/- 9.8 vs.3.75+/-7.2 mg/L, p<0.0001)). CRP serum level showed a strong, positive association with FMS (unadjusted OR for highest vs. lowest quartile=2.5 (CI 2.1,3.0; P for trend(p<0.0001); adjustment for demographics and lifestyle factors attenuated but did not eliminate this association (adjusted odds ratio (AOR) for highest vs. lowest quartile = 1.4, (CI 1.1, 1.6). The addition of body mass index (BMI) and comorbidities to the model further weakened the relationship between CRP and FMS (AORs, respectively, for highest vs lowest CRP quartile=1.2 (CI 1.0,1.4) and 1.1 (CI 0.9, 1.3), suggesting that these factors may partially explain the observed associations. Study 2: In our sample of 301 WV chronic pain patients, 8% reported using herbs and 58.8% reported using other CHAs, including mind-body practices (28.9%),; acupuncture, manipulative treatments, massage, and/or movement therapies (28.1%), and non-herbal dietary supplements (53.6%). Herbal use in this sample was marginally, inversely associated with age (OR adjusted for education=0.97 (CI 0.94,1.01) and positively associated with education (OR adjusted for age=4.94 (CI 1.6,15.3); Herbal use also showed strong positive associations with use of other CHAs ( (AOR=11.5 (CI 1.5,87.9); specific CHA AORs ranging from 2.4 to 10.3). Use of other CHAs was marginally, inversely associated with age (OR adjusted for education/exercise=0.98 (CI 0.96,1.0), and significantly and positively associated with education and physical activity (AOR's for Bachelor's+ vs.