In the past decade relaxation training has been one of a number of behavioral approaches to the treatment of chronic pain. Recently, flotation REST (Restricted Environmental Stimulation Therapy), which consists of floating in buoyant liquid kept at skin surface temperature in a sound-proof, light-free enclosure, has been used to induce deep states of relaxation and assist in the relaxation training process. This report presents data on patients receiving multimodal treatment for chronic pain, including REST-assisted relaxation training. The patients received individual stress-oriented psychotherapy, biofeedback-assisted relaxation training and REST assisted relaxation training. The use of flotation REST will be discussed through a comparison of the subjective effects of REST relaxation of biofeedback assisted relaxation specifically regarding the perception of pain.

Introduction
Treatment of pain disorders has undergone a refocusing of efforts in recent years. The movement has generally been away from the external management of pain perception through medication or surgery; towards the internal regulation of pain experience through behavioral management, (Fordyce & Steger, 1979) relaxation training (Turk, Meichenbaum and Genest, 1983) and cognitive-behavioral approaches (Turk, et.el., 1983). These approaches have been used extensively with various pain disorders including chronic, recurrent pain and chronic intractable, benign pain (Turk, et.al., 1983).

As mentioned, one component of this treatment approach has been relaxation training. Often the relaxation training is assisted through the use of EMG or thermal biofeedback. The rationale for this is simply that biofeedback provides specific training for physiological processes enhancing the generalized relaxation instructions. In addition biofeedback may provide motivational factors not available in relaxation training alone.
The goal of relaxation training is for an individual to be able, through the use of an internalized set of cues, commands, images, phrases or kinesthetic sensations, to alter his or her physiology to a state of reduced output. Any process that assists an individual in experiencing that state may prove useful in a behaviorally oriented chronic pain therapy.

Flotation Restricted Environmental Stimulation Therapy (Flotation REST) has been shown to create powerful physiological and subjective relaxation states (Turner & Fine, 1983, Suedfeld, 1983, Jacobs, Heilbronner & Stanley, 1984). This technique involves flotation in a lightproof, sound attenuated chamber containing a thermally constant (94.5 degrees) buoyant (1.28 s.g.) solution of epsom salts and water. Flotation REST in combination with relaxation training, stress management and biofeedback has been used experimentally and clinically for stress related disorders (Jacobs, Kemp, Belden, 1983, Fine & Turner, 1983). This report describes the use of flotation REST as part of a multimodal program for chronic pain.

Methods
Fifteen patients (ten males and five females) were referred to the Behavioral Medicine Clinic of the Medical College of Ohio for a chronic pain disorder by their current attending physician. Eight patients were treated in an outpatient program, seven patients were treated on an inpatient unit. Ten patients had daily, chronic low back pain, three patients had daily chronic shoulder pain, and two patients had chronic headaches at least once per week. The number of years with pain ranged from .25 to 16 with a mean of 7.3. Patients were treated on the inpatient unit if a) a psychiatric condition (i.e. depression) was considered significant to warrant admission or b) environmental conditions made outpatient treatment unfeasible (length of drive for treatment). Each patient’s treatment began with a thorough interview. This interview covers the patient’s pain
disorder and psychosocial information about the patient. Throughout the treatment process the therapist worked with the patient on significant psychosocial factors as well as relaxation oriented interventions. Treatment consisted of relaxation training (autogenic phrases and/or progressive relaxation) EMG and/or thermal biofeedback, stress oriented psychotherapy and flotation REST. In addition inpatients participated in a milieu therapy program including occupational therapy, group therapy and exercise therapy. After the initial interview session, each patient’s psychophysiological baseline was recorded using frontal and/or neck EMG and
peripheral temperature measurements. The therapist then instructed the patients how to use a modified autogenic training relaxation exercise for regular home use. Patients then use EMG frontal and/or neck biofeedback during one hour sessions in the clinic. The number of feedback sessions ranged from 6 to 36 with a mean of 13. Actual feedback training is for 25 minutes and the other time is used for psychotherapy. REST was introduced to the patient after the patient maximized the effects of the biofeedback training. REST was introduced to a) increase the depth of the subjective experience of relaxation and b) increase the subjective sense of reduction of pain during relaxation.

Procedures for flotation REST involved flotation in the REST chamber either nude or in a bathing suit. During flotation, and after an initial period of silence ranging from 10-25 minutes, a tape recording of the autogenic phrases was played. As treatment sessions progressed some patients were asked to use the phrases without the tape, and some were also given imagery suggestions specific to their situation. REST sessions were between 40 and 60 minutes long, the length chosen by the patient. The number of REST sessions varied from 2 to 18 with a mean of 7. Patients rated their pain experience using a scale of 0-6 on pain log sheets. Patients rated the depth of relaxation achieved on a scale of 0-10 in a follow-up interview.

Results
The results presented here are taken from the patients’ clinical records at the end of treatment and a follow-up conducted at least three months post treatment except for two patients still in long term treatment. For the 13 patients with chronic intractable benign pain there was a difference in intensity but no differences in frequency or duration of pain after treatment. For the two patients with chronic recurrent pain, all three subjective pain rating measures changes. (See Table 1). Twelve patients stated that they regularly used relaxation to affect their pain, and were able to reduce it. Patients subjectively rated the REST relaxation as more relaxing and more pain relieving than the Biofeedback Assisted Relaxation (Fig. 1). Patients were asked to rate whether or not they became pain free during biofeedback or REST. Eight patients rated themselves as pain free after REST, one patient rated himself as pain free after biofeedback and 2 patients did not become pain free (Table 2). Twelve patients were not able to work because of their pain. Three of these patients are now working and one is being retrained for a less physically stressful career.

Table 1: Subjective Reports of Pain Pre/Post Treatment
Intensity Pre 1 Post 1
CIBP + CRP* N = 15 4.3 3.57 P<.10 SIG
(F=4.15,dF1,14)
Frequency
CIBP N = 13 Daily Daily
CRP N = 2 3/Week 2/Month
Duration
CIBP N = 13 Constant Constant
CRP N = 2 18 Hours 6 Hours
*Chronic Intractable Benign Pain & Chronic Recurrent Pain
Table 2: Patients Experiencing Total Remission of Pain During Relaxation
REST Biofeedback Both
8 1 2

This clinical, preliminary report examined the efficacy of REST in a multimodal program for chronic pain. Numerous reports have already established the use of relaxation training as an appropriate component of this treatment (reviewed Turk, et. al., 1983). Previous reports have show REST to be more physiologically and subjectively relaxing than relaxation training alone (Turner and Fine, 1983, Jacobs, et.al., 1984). In this report relaxation was assisted by both EMG biofeedback and flotation REST. Both were reported as effective in assisting the patients in relaxation, with patients reporting that REST was significantly more relaxing than Biofeedback. In addition, more patients were able to experience periods of complete remission of pain with REST than with biofeedback. Patients in this treatment program reported a small but significant decrease in average subjective pain experience during follow-up. Although the chronic intractable benign pain patients did not report a decrease in the frequency or duration of pain, they did regularly use relaxation as an
intervention of the pain. The patients stated that they felt that their relaxation skill was important in their ability to live with their pain. The mechanism through which flotation REST reduces pain experience is unknown. The buoyancy of the solution may provide a more supportive environment than the typical relaxation chair, allowing deeper muscle relaxation. The reduction of environmental stimulation may allow the person to better attent to previously ignored tension in the muscles, further enhancing relaxation. The lack of environmental stimulation may disrupt a cognitive component of pain by eliminating environmental cues normally associated with pain. A recent preliminary report (Turner & Fine, 1984) has indicated that the subjective effects of flotation REST can be affected by the narcotic antagonist Naloxone. This suggests that REST either increases endogenous opiod production or heightens sensitivity to existing opiod levels. This may be biochemical aspect of the subjective pain reduction.

Many of the pain patients treated expressed a desire to have a flotation REST chamber at home. For patients with chronic intractable benign pain secondary to injury, this may be a cost effective alternative that would increase their overall level of functioning, and help reduce or eliminate pain medication. In summary, this report demonstrates that relaxation training was an effective tool for reducing the subjective intensity of pain for all of the patients studied. Both Biofeedback and REST were perceived as helpful in the relaxation process, although REST was seen as significantly more powerful in affecting relaxation than Biofeedback. More pain free periods followed REST relaxation than Biofeedback assisted relaxation. Despite some methodological weakness, this report is strongly suggestive of an important role for REST in the treatment of chronic pain.

References can be viewed on the pdf download above

The research study shows that individuals suffering from stress-related health problems such as chronic pain, depression, or anxiety are often helped a great deal by floating. The effect remains four months after the treatment period. A control group, which did not participate in floating, experienced no improvement in their health. The study is part of a series at the Human Performance Laboratory and is research project run in collaboration with the Vormland County Council.

The patients who were treated with floating had had health problems for a long time. Several of them had been diagnosed with ‘burn-out.’ They had various stress-related symptoms like pain, exhaustion, depression, and anxiety.

“These are individuals who often have tried many different forms of treatment before. They are individuals who are in the greatest possible need of relaxation but who have the hardest time adopting methods of relaxation. They are so tightly wound up that the methods don’t work,” says Professor Torsten Norlander.

What happens, then, when these patients are allowed to float? It appears that floating is an effective way to trigger the body’s relaxation response. The level of stress hormones goes down during and after floating. Moreover, it seems as if the treatment has an even greater effect since prolactin, a kind of ‘life-force hormone,’ is released in larger amounts.

After a period of treatment totaling seven weeks, 22 percent of the participants in the floating group were entirely free of pain, and 56 percent experience a clear improvement; 19 percent noticed no difference, and 3 percent grew worse.

In terms of symptoms, the findings were as follows: 23 percent slept better; 31 percent experienced less stress; 27 percent felt less anxiety; and 24 percent were less depressed or came out of their depression completely.

What the researchers find particularly gratifying is that the positive effects were still in evidence four months after the floating treatment ended.

To ensure that the good results can be ascribed to floating as such, the researchers set up, on the one hand, a control group that did not take part in floating and, on the other hand, a subdivision within the floating group. One of these subgroups received normal attention and encouragement, while the other subgroup was given extra attention and encouragement.

“It might be suspected that it was the attention and encouragement that yielded results, so we wanted to try treating the two floating groups differently. But it turned out that there was no difference between the two subgroups of floaters: their results were equally good. On the other hand, the control group, which did not take part in floating, registered no improvement whatsoever,” says Sven-Oke Bood, a doctoral student in psychology and a registered nurse. This research on floating is part of his coming doctoral dissertation.

Stress is largely about how we worry about things that have happened and are going to happen. When an individual, instead, manages to reach a sort of ‘here-and-now’ state, the brain can rest. These researchers believe that floating is a way of achieving just such a state. In a dark and silent floating tank, the patient is cut off from many sense impressions. Besides the rest the brain gets, the muscles also become relaxed.

In one study the researchers found that about 12 floating treatments are sufficient to achieve results. The group that received 33 floating treatments attained only slightly better pain relief and blood pressure levels. It seems as if 12 treatments are enough to alleviate anxiety, depression, and other stress-related symptoms.

In another study the researchers examined whether floating can be combined with conversational therapy. Thus far it seems that patients who float achieve positive results more quickly during conversational therapy. Floating enhances the effect.

The research project, which has been underway since 2003, is being funded by the Vormland County Council and the Center for Clinical Research.
These research findings are being presented in the prestigious American scientific journal International Journal of Stress Management in May and in a specialist journal for pain research. 

Peer reviewed publication and references International Journal of Stress Management, May issue
Vetenskapsrodet (The Swedish Research Council)

The Swedish Research Council bears national responsibility for developing the country’s basic research towards attainment of a strong international position. The Council has three main tasks: research funding, science communication and research policy. Research is the foundation for the development of knowledge in society, and the basis of high-quality education. Research is also crucial as a means of enhancing welfare through economic, social and cultural development.

It was a totally different type of experience and definitely something I would suggest to anyone whom I talk with. I really do believe that anyone who experiences it for the first time will also feel the same.

The set up was clean and relaxed and the staff were just charming.

The pods are BIG and one can stretch out even in a star shape.

Once you reach the Alpha state you cannot feel the water around you because it is at the same temperature as your body.  I opted for total darkness which actually made me feel as if I were floating in space.

Helen loved it as much as I did and we will definitely be back .

- John and Helen, London UK

TURNER, JOHN W., JR., AND THOMAS H. FINE. Restricting environmental stimulation influences levels and variability of plasma cortisol. J. Appl. Physiol. 70(5): 2010-2013, 1991.-

SUMMARY

Restricting stimulation from the environment has been shown to alter psychological and physiological states. The present study of 27 healthy subjects examines the effects of restricted environmental stimulation technique (REST) on plasma levels of cortisol and variability in plasma cortisol levels across repeated REST sessions.

The REST environment consisted of a 1.2 X 1.2 X 2.4-m ovoid chamber containing 25 cm of saturated MgSO, solution (sp gr 1.28) maintained at 34.5OF. The buoyant supinely floating subject experienced a minimum of light, sound, and temperature awareness and spatial orientation.

The non-REST environment was a cushioned reclining chair in a quiet dimly lit room. The 5wk protocol consisted of four visits for blood sampling during a 2-wk baseline followed by eight REST or non-REST sessions, 40 min each, with blood samples taken on four nonsession days between sessions 5 and 8. Variability in plasma cortisol was expressed in terms of standard deviation.

REST was associated with across-session decreases of 21.6% in plasma cortisol and 50.5% in plasma cortisol variability, whereas no changes in these measures occurred in non-REST. It is concluded that REST influences both static and dynamic aspects of drenocortical function, possibly altering the feedback monitoring of plasma cortisol.

INTRODUCTION

Increased levels of plasma cortisol in humans have been reported in association with a variety of psychological and physiological stress conditions (13, 16). Conversely, decreases in blood pressure (BP) (3, 7) and plasma levels of several hormones, including cortisol(22) and aldosterone and renin activity (12), have been reported in association with repeated brief exposure to a sensorily restricted environment. One version of this condition is flotation REST (restricted environmental stimulation technique), in which the individual lies supinely in thermoneutral buoyant fluid with minimized photic, auditory, and tactile stimulation (9, 19).

To date, studies of the relationship of restricted sensory input to physiological activity have been limited to point-in-time measurements of given parameters, which give little information on the dynamics of the system. One possible dynamic measure of a system is the variability of its measured parameters (6, 15), and standard deviation (SD) around mean values for a given parameter is a statistic that describes such variability.
The involvement of central nervous mechanisms in the dynamic regulation of physiological systems has been evidenced in several studies of BP regulation. Increased variability in mean arterial BP has been demonstrated in several species after disconnection of baroreceptor input to BP regulation (2, 11, 21). Because flotation REST (henceforth, REST) greatly attenuates the input of sensory information about light, sound, kinesthetics, and temperature, it was of interest to assess the possible impact of REST on dynamic aspects of physiological regulation.

Plasma cortisol was chosen as the monitored parameter for the present study on the bases that REST effects on the activity of this hormone have been previously demonstrated (8,15) and feedback regulation of plasma cortisol has been well researched. In this study the effect of brief repeated REST on plasma levels of cortisol and their variability is examined. The study is designed to minimize the amount of protocol-related disruption that subjects experienced in their normal daily life.

MATERIALS AND METHODS

Twenty-seven healthy subjects (18 males, 9 females) ranging in age from 21 to 32 yr were recruited. A brief medical history was taken, and subjects were screened for normalcy of sleepwake cycles and diet and for absence of adrenal-stimulating medications. Three subjects dropped out during the study for personal reasons unrelated to the study. The subjects were pair-matched on the basis of initial midday values of the measured end point, plasma cortisol, and were split into a REST group (n = 15, 5 females) and a non-REST group (n = 12, 4 females). The REST condition consisted of a 1.2 X 1.2 X 2.4-m ovoid chamber (Enrichment Enterprises, Huntington, NY) completely enclosed and filled to a 25-cm depth with saturated MgSO, solution (sp gr 1.28) maintained at 34.5OC. The buoyant supinely floating subject experienced the absence of light
and a minimum of sound (~10 dB), temperature awareness, and spatial orientation. The non-REST condition consisted of a cushioned reclining chair, fully reclined in a warm (29°C) quiet (~30 dB) dimly lit (~1 ft cd) room. The 5-wk protocol was identical for each subject and consisted of four visits for blood sampling during a 2-wk baseline followed by eight REST (or non-REST) sessions, one every 3rd day for 3 wk. Blood samples were taken on the day before sessions 5-8. Samples were taken by an experienced phlebotomist via forearm venipuncture into heparinized tubes and were immediately centrifuged. The plasma was frozen and stored at -
6OOC until assayed for cortisol by radioimmunoassay (kit code KCOD2, Diagnostic Products, Los Angeles, CA).

The blood sampling protocol was designed in consideration of the diurnal variation and episodic secretion patterns of cortisol (25) such that, for each blood sampling visit,
1) the subject arrived and sat quietly for 5 min before sampling,
2) blood was drawn between 1200 and 1400 h, and
3) each blood sampling event consisted of two samples, 10 ml each, taken 20 min apart.

Thus for each subject there were four sampling sessions in baseline and four in treatment, with a and b samples in each session. Determination of the reproducibility of values in the paired a and b samples provided a means to assess reliability of the cortisol measure in each session, because significant changes in plasma cortisol over 20 min were unlikely under these conditions (1,27). The overall difference between a and b samples was 7.8%, and a and b samples for each session were pooled. Because of potential effects of meals on cortisol release, all subjects were instructed to eat their regular breakfast and not to eat lunch until after the blood sampling session on sampling days. For each treatment session the subject undressed, showered briefly, experienced REST or non-REST for 40 min, showered again (REST only), dressed, and departed. Average total session time was 70 min. Subjects were encouraged to discuss a given session when it was over and were requested to report any unusually stressful experience during the study. A brief subjective report questionnaire was completed by each subject after each treatment phase session.

RESULTS

Plasma cortisol data are presented in Fig. 1. These data were subjected to two-way repeated measures analysis of variance. Hypothesis testing for cortisol data was accomplished with the parametric Tukey’s test and F test (18). There were no differences among sessions within baseline or among monitored sessions within treatment in either the REST or non-REST groups.

In other words, plasma cortisol levels did not change significantly during baseline or during the portion of treatment that was monitored in either REST or non-REST. Plasma cortisol values in REST treatment were lower (P < 0.05, Tukey’s test) than in REST baseline, non- REST baseline, and non-REST treatment. Cortisol values in the latter three were not different. The mean cortisol level (across sessions and subjects) was 11.29 t 0.37 (SE) pgldl in REST treatment and 14.21 t0.82 in REST baseline. As a dependent variable in this study, variability refers to the classical statistical definition of measures of dispersion and is reported as SD, which is the square root of the variance iN SD= \/C (Xi-X)2/N-i V i=l For each subject, SD was calculated across samples for baseline (4 cortisol values) and treatment (4 cortisol values). These individual SD values were then averaged across subjects in baseline or in treatment to yield SD values as follows: REST baseline, REST treatment, non- REST baseline, and non-REST treatment.

To account for the possibility that lower SD values in a given condition were simply the consequence of plasma cortisol values being lower, the coefficient of variation (SD/Z 100) was determined for each SD. Plasma cortisol variability, reported as SD and as coefficient of variation (Table l), was subjected to statistical analysis. Although parametric statistics are normally more robust than nonparametric statistics, the latter do not require normalcy of distribution and equal variances in the sample populations to be compared. Because it was hypothesized that variability could be influenced by TABLE 1. Effect of repeated brief REST on variability of plasma cortisol values REST (n = 15) Non-REST (n = 12) Baseline Treatment Baseline Treatment Plasma cortisol, cLg/dl SD CV 14.21 11.29 13.77 14.14 3.86 1.91* 3.51 3.77 29.86 18.56* 26.85 30.06 n, No. of subjs. Values were calculated for 4 samples from each subject and then averaged across subjects in each group. REST, restricted environmental stimulation technique; SD, standard deviation; CV, coeff of variation [(SD of cortisol value/cortisol value) X 1001. * Different from Baseline (P < 0.005, Wilcoxon matched pairs test). 2012 RESTRICTED ENVIRONMENTAL STIMULI AND PLASMA CORTISOL treatment in this study, data were tested for significant differences by a nonparametric test. The SD and coefficient of variation were 50.5 and 37.9%, respectively, lower in REST treatment than in REST baseline, and the changes in both parameters were significant (P < 0.005, Wilcoxon matched pairs test).

In the non-REST group there was no difference in either SD or coefficient of variation between baseline and treatment. Eighty-seven percent of the REST subjects showed decreased plasma cortisol across sessions, and 93% showed decreased SD for cortisol. A Pearson correlation was performed on REST group data, comparing acrosssession percent change in plasma cortisol with acrosssession percent change in the SD of plasma cortisol. These changes were not correlated (r = 0.12; NS, P > 0.05, df = 13).

DISCUSSION

Both the concentration and the variability in concentration of cortisol in plasma were decreased across sessions in the REST group, whereas no changes occurred in the non- REST group. These data suggest a REST specific effect on the activity of the adrenal cortex or the clearance of cortisol or both.

The present study does not differentiate between these possibilities. Although the metabolic clearance rate (MCR) for cortisol has been shown to increase 19-30% after exogenous pharmacological- dose ACTH administration (27), it appears unlikely that cortisol clearance changes significantly in unstressed individuals (1, 20). In the present study of unstressed healthy subjects, mean plasma cortisol decreased 21.6%. The
decrease in plasma cortisol levels was not surprising, because previous studies have demonstrated decreased plasma cortisol across REST sessions in normal subjects (22).

The decrease in variability around the mean value of plasma cortisol from baseline to treatment in the REST group, but not in the non-REST controls, suggests that the conditions of REST can influence the dynamic state of cortisol regulation. The coefficient of variation data demonstrate that the decrease in variability is not due simply to smaller SD values accompanying smaller absolute cortisol values. In fact, the results of the Pearson correlation show that changes in plasma cortisol and changes in the SD of mean plasma cortisol were not significantly correlated.

This suggests that the effects of REST on absolute cortisol levels can occur independently of the REST effects on the variability of cortisol levels. It is known that cortisol exhibits episodic pulsatile release (8), with considerable variation occurring within and between individuals (10,25). Also, it has been shown that there is a cortisol peak associated with mealtimes (4). These factors may have contributed a significant “noise” component to the variance data. However, it appears that the REST effect was robust enough to have a discernible impact on variability, because SD values were decreased across treatment in REST but not in non- REST.

Sampling was too infrequent in the present study to determine whether changes in pulse frequency or pulse height were associated with REST. A large number of blood samples taken 15-20 min apart would be necessary for analysis of pulsatile release characteristics (23, 24). Such analysis would require the use of an in-line venous catheter. This approach was not chosen for this study, because it precluded assessment of the effect under “normal” circumstances. The present study was designed to minimize the amount of disruption that subjects experienced in their normal daily life. This was done to monitor the dynamic physiological system across time under “natural” everyday conditions. A more radical monitoring such as in-line blood sampling over many hours might confound the interpretation of the treatment effect. Although the control
condition could potentially obviate this problem, there is the possibility that the stress associated with extended intravenous monitoring would wash out the REST effect. The present study is, to our knowledge, the first report of external environmental conditions influencing the variability of plasma cortisol levels.

In the conceptual framework of cybernetic theory, variability is one measure of the dynamic state of a negative feedback loop (15, 26). Plasma cortisol is one component of an integrated negative feedback loop. Thus plasma cortisol variability is one reflective measure of the dynamics of physiological regulation. In the present controlled study,  the intervention (REST) was associated with a change in plasma cortisol levels and variability over time; i.e., REST influenced both the total output and the dynamics of the physiological sys em.

This result is consistent with other studies in which variability in a measured parameter was influenced by a central nervous system-mediatedintervention. For example, Cowley et al. (2) observed increased variability in mean arterial pressure after BP baroreceptor disconnection in dogs, various mental and physical stressors have been shown to influence BP variability in humans (5,17), and Porges (14) reported decreased variability in heart rate in association with increased attention to a reactiontime task. It should be noted that these studies examined immediate response dynamics, whereas the present study examined longer-term dynamics. It has previously been reported that repeated REST can be associated with cortisol changes that persist
for days beyond the REST sessions (22). Likewise, REST effectiveness in BP reduction in essential hypertensives may continue for weeks to months beyond cessation of treatment (3, 12).

This raises the possibility that REST may contribute to reorganization of set points for the operation of physiological feedback loops. The cortisol variability data in the present study are consistent with such a hypothesis, although they do not address either the mechanism by which REST affects plasma cortisol levels or whether REST specifically facilitates or improves feedback regulation of plasma cortisol levels.

References can be found in the pdf download above: Influences_plasma_cortisol.pdf