Health and Clinical Psychology magazine (1985)
By Thomas H. Fine & John W. Turner, Jr., Medical College of Ohio, Toledo, Ohio, USA
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.
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.
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.