Journal of OsteopathicMedicine,2001; 4(1): 25-30 AOMRInc.

2001

Case Report

Pain management in osteopathic medicine: The efficacy of

flotation REST as an adjunct to spinal manipulation for acute
non-specific low back pain. A case report
Anthony Rogan, Tony Morris, Peter Gibbons.
School of Health Sciences, Victoria University, PO Box 14428MCMC,Melbourne8001,Australia

Abstract
Spinal manipulation is a commonly used modality for the treatment of low back pain with increasing
evidence of positive outcomes. Adjunctive therapies such as hydrotherapy, flotation and exercise
prescription are also used with effect for a range of clinical conditions including low back pain.
This report introduces the potential role of combining spinal manipulation and adjunctive Flotation
Restricted Environmental Stimulation Therapy (Flotation REST) in the treatment of acute non-
specific low back pain. Outcome measures were used to assess the effectiveness of this
combination of therapies and demonstrated both amelioration of pain and improvement in level
of disability. The results support implementing a more detailed study with larger numbers of
participants.
Key Words: Low back pain, Spinal manipulation, Flotation REST, Outcome measures

Introduction
80% of adults will suffer from lower back pain at some point
during their lives.lLow back pain (LBP) not only decreases
quality of life, it increases work loss, and is a significant
part of the rising cost of health care.~,z,3,4Despite improved
understanding of LBP the incidence of disability resulting
from LBP is on the increase? A shift in cultural and indi-
vidual perceptions of health, disease and learned patterns
of illness behaviour contribute to LBP being a chronic
healthcare problem.6
evidence. Bogduk and Mercer 14discussed in detail the im-
perative that manual therapists should utilise therapies
that have undergone rigorous RCTs and have demonstrated
efficacy. It is their contention that the majority of manual
therapists select techniques and therapies because it is
convention to do so. Whilst there are many therapies with
plausible explanations for their mechanism of action,
Bogduk and Mercer TM state that scientific proof of the
biological or physiological basis is lacking.

The use of case reports in scientific literature is common as
they facilitate an in depth review of an individual case, are
useful in inducting novice researchers into clinical research,
and can provide preliminary data prior to a more detailed
research study, y, 8This report introduces the possible role
of Flotation Restricted Environmental Stimulation Therapy
(FR) as an adjunct to the treatment of acute non-specific
LBP by spinal manipulation (SM).
Low Back Pain
LBP is the most c o m m o n complaint presenting to
osteopaths, indeed to all manual therapists, and manual
techniques for treating the lumbar spine will probably be
used more often than any others in practice. 9,4 SM has been
labelled by the medical profession as unorthodox 1and some
randomised clinical trials (RCTs) of the efficacy of SM have
been equivocal.H'~2'13The fact that LBP is a symptom, not a
disease, leads to an enormous amount of speculative
treatment and exercise prescription deeply rooted in clinical
experience and practitioner bias, not based on scientific
Even if the mechanism is unknown, a therapy may still be
scientifically valid, providing the research is rigorously
scrutinised - "The science lies in the testing and not in
knowledge of the mechanism. ''14Clinical outcome studies
are required to evaluate the effects of manual therapies upon
patients. All practitioners working in the manual medicine
field should, where possible, base treatment upon known
evidence and provide appropriate effective, evidence based
therapy at reduced costs. 15,16,14One of the challenges for
osteopathy and other manual medicine disciplines is to
scientifically validate current and new methods o f
management of LBP, and ensure that they represent an
effective and cost-effective approach for the short and long
term management of LBP and other conditions.
Clinical Measures of LBP
The extraordinarily complex nature of LBP, particularly of
chronic LBP, poses numerous methodological problems for
researchers. Presenting complaints are frequently
complicated by psycho-social and other factors, pain is

25
 AOMR Inc. 2001 Rogan A et al. Pain management in osteopathic osteopathic medicine: A case report.
subjective and h o m o g e n o u s samples of specific
populations are difficult to obtain. 17,18The vast majority of
research measuring pain and improvement of symptoms
has used in isolation, or in combination, verbal rating scales,
visual analog pain scales, and disability/functional capac-
ity questionnaires. 19,20, 2I, 22
Questionnaires can measure the patient's presenting level
of pain and disability and identify change after treatment
and over time. The clinical measures used for this report
were the Revised Oswestry Low Back Pain and Disability
Questionnaire (ROLBPDQ), Visual Analog Pain Scale
(VAPS) and Profile of Mood States (POMS). They have
been used in clinical outcome studies and have shown to be
reliable and valid measuring instruments. 23, 26, 27
The ROLBPDQ is a 60 item inventory that measures ten
indicators of LBP and disability. These include pain intensity,
personal care, lifting, walking, sitting, standing, sleeping,
social life, traveling and changing degree of pain. It has
been shown in RCTs to have validity and reliability in
measuring results for patients with LBP. The questionnaire
takes 3-5 minutes to complete and 1 minute to score. 24The
VAPS requires patients to mark along a 100mm line, the
level of pain they are experiencing. The ends of this line are
labelled "no pain" and "worst possible pain". The patient is
asked to make a perpendicular line along the 100mm scale
indicating the level of pain they are experiencing (see Figure
1).
Worst
No Possible
Pain Pain
0 mm 100 mm
Figure 1. Visual Analogue Pain Scale
The researcher records how many millimetres along the line
the patient makes the mark and interprets this measurement
as a percentage. Waddel125 recommends the use of a "pain
thermometer", a vertical VAPS. The VAPS has been shown
to be a reliable and useful measuring tool in combination
with the ROLBPDQ. 26The POMS is a 65 item questionnaire
that measures six mood states: Tension, Depression, Anger,
Vigour, Fatigue and Confusion. McNair, Lorr and
Droppleman 27 developed the POMS and it has been used
extensively in psychology research. McNair et al27report
strong reliability and validity over more than 15 years of
use.
Adjunctive Therapies
Adams 28 indicates that treatment of LBP is becoming
multimodal and multi-disciplinary due to the recognition of
the number of factors involved in the aetiology and
perpetuation of LBP. Symptomatic improvement rates and
pain management might be enhanced by the use of adjunctive
therapies. Many different forms of adjunctive therapies are
in use including exercise prescription, relaxation techniques,
yoga, meditation, nutrition and diet, massage and
psychotherapy. The use of water, predominantly in
26
hydrotherapy, is common and dates back to the times of
Plato and Hippocrates. 29 Water is of benefit due to its
property of buoyancy that can reduce gravitational forces
and relieve stress on weight-bearing joints. 3 This may lead
to a reduction in muscle tone and pain? 1.3z.33
This report introduces the question of whether the use of
adjunctive therapies in the management of LBP, together
with SM might produce better outcomes for patients than
manipulation alone? And fitrthermore, is FR an effective
adjunct to SM in the management of LBP?
Acute LBP and Spinal Manipulation
Manipulation of the spine has been shown to be of benefit
to patients with musculoskeletal complaints?, 34Acute LBP
is classified by convention as pain in the lumbar spine or
pelvic regions that has a duration of less than six weeks. 12
Non-specific LBP or "simple" LBP is "mechanical" pain of
musculoskeletal origin. It may be extremely painful and refer
into the buttocks or thighs. 5 Clinical guidelines issued in
the United Kingdom by the Royal College of General
Practitioners include spinal manipulation for relief of
symptoms of acute non-specific LBP within this time
period. 35
Flotation REST (FR)
FR is a descendant of perceptual isolation studies carried
out in the 1950's? 6 These studies examined how humans
are affected by a reduction in different aspects of
environmental/exogenous stimulation and were later
commonly known as sensory deprivation. The early studies
revealed that after initial positive effects (emotional and
psychological), participants generally suffered unpleasant
and aversive reactions to the experimental conditions? 7
Scrutiny of these early experiments suggested that their
results were unreliable and the studies were not
reproducible. 38 Among these early researchers was
neurophysiologist, John C. Lilly, who in the early 1970's,
invented and designed FR as it is used today. Research into
the effects of FR has been conducted predominantly in the
fields of psychology and psychophysiology. Psychological
and psychophysiological measures have consistently shown
that FR leads to deep states of relaxation. 39'37,40The logical
extension of this, as stated by Suedfeld4, is that it can be
used to treat conditions related to tension such as headaches,
hypertension, insomnia, muscle aches, pain and stress.
FR is an environment in which buoyancy is greater than
that of a hydrotherapy pool, and gravitational and
compressive loads are further reduced. FR involves the
patient floating supine in a 34.5C dense Epsom Salts
solution in a lightproof and soundproof tank (see Figure
2). The patient floats effortlessly with their entire body fully
supported (see Figure 3). FR has been shown to decrease
pain and improve functional capacities in several studies.
Mereday, Lehman and Borrie conducted a pilot study into
the effects of FR on patients with rheumatoid arthritis. 41
Ten participants were involved in the study, of which six
showed significant reduction in pain and an increased ability
to move.
Journal of Osteopathic Medicine, 2001;4(1): 25-30
Figure 2. Apollo flotation tank.
Figure 3. Inside the Apollo flotation tank
Turner, De Leon, Gibson & Fine conducted a pilot study
into the effects of FR on range of motion (ROM), grip
strength (GS) and pain in people suffering from rheumatoid
arthritis. 4z They found that FR increased ROM and GS, as
well as decreasing pain. Other research into the effects of
FR on pain has been encouraging. Studies of patients with
chronic tension headaches 43and pre-menstrual syndrome44
both reported subjective improvement of symptoms (self-
rating measures of intensity, frequency and duration of
symptoms).
There are several different theories on the beneficial effects
of FR. One is based on neuroendocrine activity. Research
has indicated that FR decreases the levels of stress-related
neurochemicals, such as nor-adrenaline, adrenaline,
adrenocorticotrophin and cortisol. 45,46 Preliminary studies
have also shown that the opiate antagonist, naloxone,
inhibits the mild euphoria normally associated with FR. It
has been hypothesised that the euphoria associated with
FR may be the result of increased production of endogenous
opioids (endorphins) or the result of increased sensitivity
of opioid receptors. 47Endorphins are a powerful analgesic
in humans.48 FR has been shown to induce deep relaxation.37,
49.50Relaxation decreases muscle tension/hypertonicity and
sympathetic neural output. TM 52 This leads to greater
peripheral blood flow due to vasodilation 28and subsequent
increases in tissue perfusion of areas previously in a state
of relative hypoxia and haemostasis.
It has been reported "... 90% of all the activity affecting
the central nervous system is related to gravity. ''53Floating
in water distributes the effects of gravity over the greatest
possible area therefore decreasing central nervous system
(CNS) stimulation. Theoretically, this makes available large
amounts of energy otherwise utilised by the CNS and
musculoskeletal system in handling the effects of gravity
on the body, to contribute to other matters of mind, spirit
27
AOMR Inc. 2001
and an increased awareness of internal states. This may
potentiate homeostatic mechanisms. Sniffen et al
hypothesised that the magnesium in the Epsom Salts solution
is a trans-cutaneous muscle relaxant, though this is yet to
be tested. 51
Case Report
A 26 year-old female who works as a full-time registered
nurse presented in the clinic, complaining of acute LBP.
The pain was described as a deep, dull and diffuse ache in
the region of the sacroiliac joints (SIJs) with radiation into
the gluteal region bilaterally. The pain was more noticeable
on the right-hand side. There was no radiation of pain into
the lower extremities and no associated motor or sensory
phenomena indicative of radiculopathy.
The patient reported stiffness in the low back on awaking
five days prior to her visit. By midday that day at work, she
was experiencing acute pain in the region of the SIJs. She
continued her nursing duties for the day, which involved no
further lifting. The patient then rested for the remainder of
the day. The pain improved dramatically over the following
days and did not hinder her ability to carry out her usual
activities of daily living. This included work, although the
patient did state that she avoided any heavy lifting. She
rated the pain at its worst, according to the VAPS as 84mm/
84%. The patient rated her pain at the time of the first
consultation according to the VAPS as 10mm/10%.
Aggravating factors were related to levels of activity and
sitting for longer than 20 minutes. Relieving factors were
gentle self-stretching and self-massage. No anti-
inflammatory medications or analgesics had been taken. The
patient had not previously experienced this type of pain.
Her only history of previous LBP was a very mild,
generalised ache in the thoraco-lumbar region which she
associated with a busy succession of work days. The
patient's general health was reported as good. The patient
reported nothing abnormal nor any "red flags" in her past
medical history or the systemic enquiry. She participates in
yoga twice a week and plays netball once a week. The
patient has been a smoker of 5-10 cigarettes a day for 6
years and drinks alcohol on a social basis.
Assessment and examination procedures revealed decreased
ranges of active flexion and extension caused by pain.
Lumbar passive ROM was considered good. Lower limb
neurological examination, straight leg raise test, slump test
and lower quadrant test were negative. SIJ pain provocation
tests (compression, shear and Gaenslen's) were positive on
the right hand side. This caused the patient's familiar pain
to be more severe. Active resisted hip flexion also produced
the patient's familiar pain. Muscle guarding was apparent
and tenderness reported on posterior I~ anterior springing
of L4 and L5 segments. A diagnosis of acute non-specific
LBP was made. The patient was treated using cross-fibre
kneading of the lumbar erector spinae and gluteal
musculature, high velocity low amplitude manipulation of
the L5-S1 segment and right SIJ, and articulation/
mobilisation of the lumbar spine and pelvis. The duration
of the treatment was 25 minutes.
 AOMR Inc. 2001 Rogan A et al. Pain management in osteopathic osteopathic medicine: A case report.

Three days later the patient underwent the adjunct, FR. The patient's scores for the ROLBPDQ were: pre-treatment
This involved the patient floating supine in a supersatu- 30% (moderate disability), 2 weeks 28% (moderate
rated Epsom Salts solution inside an Apollo T M flotation disability) and 4 weeks 16% (minimum disability) (see Table
tank. The temperature of the solution was approximately 2).
skin temperature (34.5 C). The face and ventral portion of
the body floated above the water line. The flotation tank Revised Oswestry low back pain & disability
was dark, soundproof and linked by an intercom to the questionnaire
control room where a qualified researcher was supervising Score %
the session. The patient was instructed to relax during the Pre-treatment 30%
float. The supervisor checked that the patient was comfort-
able periodically and roused them slowly with quiet music 2 Weeks 28%
at the end of the 25-minute session. 4 Weeks 16%

The patient was treated on another three occasions, each
of the treatments one week apart. Each week, the adjunct
FR treatment, followed three days after the osteopathic SM
treatment. The week following the first treatments, there
was some temporary relief for two days post-FR. The pain
was then reported as having returned to its previous intensity
of the initial consultation. The week following the second
treatment, the patient had relief from pain for the majority
of the week. The frequency of the pain had diminished,
however, the intensity of the pain, when it was apparent,
was as previously experienced. The week following the third
treatment, the patient had been pain-free since the last FR
session. The patient reported her pain according to the VAPS
as 0mm/0%. The osteopath determined that she would no
longer require treatment if she continued not to experience
any symptoms after that day's treatment. The patient did
attend her FR session that week. She was asked to telephone
the researcher on the morning of the next scheduled SM
treatment if she continued to experience no symptoms and
cancel the subsequent appointments, which she did.
Table 2. Patient R O L B P D Q scores
On closer examination of the ROLBPDQ, the main
improvements were in the "pain intensity" and "changing
degree of pain" sections, which is supportive of the VAPS
scores. Interpretation of all six mood scales of the POMS
questionnaire showed no significant changes over the
treatment period. The patient's pre-treatment, 2 week and
4 week raw scores were low and showed little change. When
compared with mean raw scores from patient normative
samples 27, the patient's raw scores for the negative scales
Tension, Depression, Anger, Fatigue and Confusion are
lower. Patient raw scores of the scale Vigour, a positive
scale, were higher than those of the patient normative
samples. 27 These scores indicate that the patient had a
positive mood state (see Table 3).
Tension Depression Anger Vigour Fatigue Confusion

Mean
Interpretation of Clinical Outcome Measures normative
15.5 17.7 9.4 9,8 8.4 10.8
raw
The patient reported that all the clinical measures used were scores
easy to u n d e r s t a n d and complete. M e a s u r e s were
Pre-treat-
administered pre-treatment and at two-weekly intervals. The 10 5 5 19 4 1
ment
patient was asked to complete a post-treatment set of
2 weeks 7 12 3 15 ,8 2
measures and return them by post, however failed to do so.
The patients VAPS scores were: pre-treatment 10%, 2 4 weeks 3 4 1 16 5 0
weeks 12% and 4 weeks 0% (see Table 1).
Table 3. Patient POMS raw scores

Visual A n a l o g u e Pain Scale

Score % Discussion

P re-treatment 10%
It is clear that there is a need for further research into the
biological, physiological and psychosocial aspects of LBP.
2 Weeks 12% Improvement in the management of LBP should continue
to be the pursuit of all professionals who have a genuine
4 Weeks 0%
concern for their patients, both for their physical ailment
and the cost-effectiveness of treatments. It is imperative
Table 1. Patient VAPS scores
that researchers of LBP undertake more clinical outcome
studies, with the explicit aim of assessing the effectiveness
of commonly used management and therapeutic techniques.
Although the patient had reported her pain at worst Studies within the last 30 years have frequently utilised
according to the VAPS at 84%, this was prior to the initial clinical outcome measures, such as those used in this report
consultation. All that can be ascertained from these scores and have been shown to be valid and reliable. 23'26.27Clinical
is that from the time of the initial treatment, she was in mild outcome studies can be undertaken with relative ease and
pain only and by the fourth week was experiencing no pain. at lower financial costs than m a n y more c o m p l e x

28
Journal of Osteopathic Medicine, 2001; 4(1): 25-30
methodologies involved in investigating the causes of back
pain and the mechanisms of treatment effects. 15,16,14
The patient was pain-free after four weeks of treatment
and remained so at the time of follow-up three months later.,
The reduction in pain and improvement in level of disability
may have been a consequence of natural recovery, and/or
resulted from the effects of SM or the combined effects of
SM and FR. A single case report cannot identify an
association between intervention and outcome but does
allow practitioners to test measuring instruments and
interventions in the process of structuring a longer-term
study that can recruit large numbers of subjects and test
hypotheses. It is possible that the deep relaxation and
neuroendocrine changes reportedly induced by FR, 45,46,47
may have enhanced the effects of the SM treatment. It is
apparent from the measures that the use of adjunctive FR
did not, in this patient, cause an exacerbation of pain and
disability. The extent of the compatibility of this adjunctive
approach should be explored further with a larger random
controlled study to compare measurable outcomes against
control and single intervention groups.
According to the POMS data, this patient had a positive
mood state and was probably tmlikely to develop depressive-
type symptoms which may have predisposed to the
development of a chronic pain syndrome. The patient's low
scores on all the negative scales and high scores on the
positive scale of the POMS support this claim. Not only
might the POMS be a useful clinical and research tool in
assessing over time the mood state of LBP sufferers, it could
also be of benefit in identifying patients who have depressive
tendencies and a potential to fall into chronic or abnormal
illness behaviour.
While rapid recovery is the immediate aim of any
intervention, consideration should also be given to possible
longer term benefits that may be reflected in lower
recurrence rates and a lower incidence of chronicity. This
may be enhanced further if coupled with patient education
and encouragement of patients to return to normal activity
as soon as possible. Investigation of these hypotheses require
large-scale RCTs with long-term follow-up periods.
Conclusion
The challenge for all manual medicine disciplines is to
provide evidence of effective and cost-effective care for a
range of presenting conditions. At the present time there is
little research to explore the potential benefits of adjunctive
approaches to speed rates of recovery and prolong periods
between relapses. This report tested an approach that could
be used for a larger study and demonstrated the usefulness
of validated clinical measures in assessing the effect of this
combination of therapies. In this case, the patient found the
measures easy to complete and the results clearly and
objectively demonstrated the patient's recovery. The use of
FR and other adjunctive approaches to SM might be valuable
in managing patients with musculoskeletal complaints,
including acute non-specific LBP. A larger random
controlled study is needed in order to determine the potential
benefits of this combination of therapies.
29
AOMR Inc. 2001
Acknowledgements
The authors would like to thank the Australian and New
Zealand fund for osteopathic research (ANZFOR) for the
generous grant given to undertake studies in the use of
flotation REST as an adjunct to osteopathic spinal
manipulation. The authors would also like to thank Float
Tank Australia Pty Ltd.
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