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Qualitative Health Research
DOI: 10.1177/1049732308315109
2008; 18; 480 Qual Health Res
Hanna Edebol, Sven Åke Bood and Torsten Norlander
Environmental Stimulation Technique)
Chronic Whiplash-Associated Disorders and Their Treatment Using Flotation-REST (Restricted
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480
Chronic Whiplash-Associated Disorders and
Their Treatment Using Flotation-REST
(Restricted Environmental Stimulation
Technique)
Hanna Edebol
Sven Åke Bood
Torsten Norlander
Karlstad University, Karlstad, Sweden
In this study, we investigated for the first time whether flotation-REST might be used for treating chronic whiplash-
associated disorders (WAD). Six women and one man, all diagnosed by licensed physicians as having chronic whiplash-
associated disorder, participated. Two of the participants were beginners with regard to flotation-REST (2 or 3 treatments),
and five of them had experienced between 7 and 15 treatments. The method for data collection was the semistructured
qualitative interview. The empirical phenomenological psychological method devised by Karlsson was used for the analy-
ses. Two qualitative models explaining the participants’ experiences of flotation-REST emerged. The models describe the
participants’ experiences of flotation-REST, as well as the short-term effects of the treatment in terms of five phases: (a)
intensification, (b) vitalization, (c) transcendation, (d) defocusation, and (e) reorientation. Results indicated that flotation-
REST is a meaningful alternative for treating chronic whiplash-associated disorder.
Keywords: whiplash; whiplash-associated disorder (WAD); WAD, chronic; restricted environmental stimulation
technique (REST); flotation-REST
W
hiplash-associated disorders (WAD) mainly arise
in connection with automobile accidents and
their numbers are increasing (Bunketorp, 2005). From
1989 until 1994, WAD went from being the third most
common traffic injury in Sweden to being the most
common (Holm, Cassidy, Sjögren, & Nygren, 1999).
While having great consequences on an individual level,
WAD also affects society at large. The costs related to
WAD in the United States are $29 billion USD a year
(Kivioja, 2004). WAD were defined and characterized
as a specific problem at the end of the 19th century,
when the railroads came increasingly into use (Kivioja,
2004). At that time, the injury was called “railway
back,” and not until 1928 was the term “whiplash”
introduced (Bunketorp, 2005). There is a difference
between the terms “WAD” and “whiplash,” because the
latter refers to the mechanisms of the actual incident,
whereas “WAD” concerns a group of signs and symp-
toms following the incident. There is also a difference
between acute WAD and chronic WAD, and the latter
term describes the case in which the symptoms are pre-
sent 3 months after the whiplash incident, whereas the
first term refers to the situation before that point. In
1991, a panel of experts on WAD from all over the
world, known as the Quebec Task Force, was set up to
review and draw conclusions from the existing docu-
mentation about WAD. The panel created a five-graded
system of WAD for the purpose of facilitating the
diagnosis and treatment of the disorder (Spitzer
et al., 1995). Grade 0 (zero) includes no complaint of
stiffness or pain by the patient and no sign of physical
neck injury. Grade I includes complaints of pain, stiff-
ness, and tenderness in the neck but no sign of physical
neck injury. Grade II includes complaints of a neck
injury and one or more signs of musculoskeletal dam-
age. Grade III refers to complaints of a neck injury and
Qualitative Health Research
Volume 18 Number 4
April 2008 480-488
© 2008 Sage Publications
10.1177/1049732308315109
http://qhr.sagepub.com
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Authors’ Note: This study was supported by grants from the
County Council (Landstinget) in Värmland (LiV), Sweden. Corre-
spondence concerning this article should be sent to Dr. T. Norlander,
Department of Psychology, Karlstad University, SE-651 88 Karlstad,
Sweden; e-mail torsten.norlander@kau.se.
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Edebol et al. / Chronic Whiplash-Associated Disorders 481
one or more signs of neurological damage. Finally,
Grade IV includes complaints of a neck injury and evi-
dence of fracture or dislocation. WAD is a very complex
disorder and its symptoms can manifest in various ways.
Common features of WAD are stiffness and pain in
the neck and back, impaired sensory system and sen-
sory hypersensitivity, psychological stress, dizziness,
headache, cognitive and visual implications, weak-
ened muscles, and posttraumatic stress syndrome
(Bunketorp, 2005). These features also coincide with the
definitions used by the physicians in the present study.
Australian researchers (e.g., Sterling, Jull, Vicenzino,
Kenardy, & Darnell, 2005) have carried out several stud-
ies on patients with chronic WAD with the help of a life
vest designed to collect data on heart and respiratory
rates, as well as leg and torso movements, through elec-
trodes, and the patients also recorded personal informa-
tion about their pain and feelings. They found that the
most common symptoms of chronic WAD are neck
pain and restricted neck movement, and up to 90%
of the 76 patients reported having these experiences.
Cervicogenic headaches were also very common and
reported by 76% of the patients. Further, lower back
pain occurred in about 50% of the cases, and was caused
by the injury to discs, facet joints, and sacroiliac joints
in the back. Other less common symptoms of chronic
WAD were tingling and pain in the arms as a result of
the nerve disturbance, and affected approximately 15%
of the participants. The actual damaged area in the neck
sometimes causes pain in other areas that the nerves
serve, such as shoulders and arms, making the effects
even more widespread and complex. Other symptoms,
found in about 10% of the participants, were problems
with memory and concentration, sleep loss, depression,
irritability, tinnitus, and/or blurry vision.
Because of the differences among WAD patients, the
work of establishing suitable methods of treatment gets
complicated. Many persons have pointed out that a
multidisciplinary approach is required when dealing
with chronic WAD (Drottning, Staff, Levin, & Malt,
1995; Mayou, Bryant, & Duthie, 1993). When planning
for rehabilitation of chronic WAD patients, it is there-
fore necessary to include somatic, psychological, and
social aspects, thus making it preferable to use a
biopsychosocial model, as it corresponds more closely
with the complexity of chronic WAD than the tradi-
tional biomedical model (Gerdle, 2004).
A project group (SBU, 2006) conducted a systematic
literature perusal of studies around methods of treat-
ment in cases of chronic pain. Those studies showed
that persons with chronic pain are often treated with
drugs that provide alleviation, but at the same time
entail a risk of strong side effects (SBU, 2006). Other
methods of treatment are acupuncture and massage,
although these have been shown to have limited effects
(SBU, 2006). Cognitive behavior therapy is a more
effective method and it helps the person to master the
pain about 25% better than with other behavior thera-
pies that were investigated, as well as with drugs, phys-
iotherapy, and with no treatment at all (SBU, 2006).
Hydrotherapy is another way of treating chronic
musculoskeletal disorders, and the effectiveness of
hydrotherapy has been investigated in a systematic
literature perusal of more than 500 studies; 34 of
them fulfilled the criteria for further analysis (Bender
et al., 2005). Ten assessed moderate- to high-quality
evidence of pain relief. Four trials were on patients
with osteoarthritis of the hip, two on rheumatoid
patients, two on patients with low back pain, one on
patients with ankylosing spondylitis, and one on
fibromyalgia. In all but one of the studies, the pain
was significantly reduced compared to control
groups. Factors such as buoyancy, immersion, resis-
tance, and temperature play important roles in
hydrotherapy (Bender et al., 2005), and muscle relax-
ation and reduced joint swellings are other possible
parts of the process, as well as improvement in mood
and tension reduction.
An examination of 26 studies dedicated to methods
of treatment of chronic WAD (Seferiadis, Rosenfeld, &
Gunnarsson, 2004) indicated that these treatments often
are of a limited quality and that the methods that,
among others, could be recommended include electro-
magnetic field therapy, radio wave neurotomy, and
cognitive behavior therapy in combination with physio-
therapy. The study also pointed out that additional
investigation regarding the effects of treatments in cases
of chronic WAD is needed. Our study is the first that
evaluates the short-term effects of the flotation-REST
treatment in cases of chronic WAD. Previous studies on
flotation-REST treatment in cases of pain and stress
have shown positive results in terms of inner well-being
and pain reduction (Bood, 2006; Kjellgren, 2003). The
short-term effects of the flotation-REST treatment in
cases with chronic WAD are therefore interesting to
evaluate.
Flotation is a mild form of sensory isolation or, to use
the more modern term, “Restricted Environmental
Stimulation Technique” (REST). The flotation form of
REST entails placing the individual in a tank of water
with an extremely high saline level, a level that is con-
siderably higher than that in the Dead Sea. However, the
salt is mainly magnesium sulphate, which is kind to the
skin. The technique involves minimizing sensory
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482 Qualitative Health Research
impressions. To achieve this, the opening in the tank is
covered by a thin lid which can be easily opened and
closed from inside. The tank is insulated on the inside
to retain heat and also to exclude sound and light.
The temperature of the water is kept at 34.2 °C. The
flotation-REST technique is not strongly influenced by
expectancy-placebo (Norlander, Kjellgren, & Archer,
2001) or by attention-placebo (Bood, Sundequist,
Kjellgren, Nordström, & Norlander, 2005). Several
studies have shown the incidence of positive effects, such
as increased well-being, mild euphoria, increased origi-
nality, improved sleep, reduced stress, reduced tension
and anxiety, reduced blood pressure, and less muscle
tension (for a comprehensive review see Bood et al.,
2006). A recent meta-analysis (van Dierendonck & te
Nijenhuis, 2005) investigated flotation as a stress-man-
agement tool. The study included 25 articles with a total
number of 449 participants, and the results showed that
the flotation-REST technique has positive effects on
physiology (e.g., lower blood pressure), well-being, and
performance.
Several studies have been performed that apply
flotation-REST as a method to alleviate different types
of pain conditions (Kjellgren, Sundequist, Norlander, &
Archer, 2001). In a series of studies with 123 partici-
pants, performed in Sweden (e.g., Bood et al., 2006),
one treatment regimen was shown to be effective, with
the positive effects of the flotation-REST therapy main-
tained 4 months after treatment. The schedule was two,
3-week periods, consisting of two treatments of 45 min-
utes each per week for 3 weeks, followed by a week
without treatment, thus giving 12 flotation-REST treat-
ments over 6 weeks (with the entire regimen lasting 7
weeks).
There has been no follow-up on this study, because
it can only be regarded as an initial evaluation of how
patients with chronic WAD experience the flotation-
REST treatment. The aim of the study was to estab-
lish a first picture of the short-term effects of the
flotation-REST treatment in cases of chronic WAD.
We were also interested in whether other possibilities
exist to carry out further studies within this area.
Method
Respondents
The participants in this study were six women
and one man, all being diagnosed as having chronic
WAD by licensed physicians. Because the number of
subjects with both chronic WAD and experiences of
the flotation-REST treatment were limited when the
study was carried out, the sample constitutes the persons
who were available and interested at that time. The
physical pains that the participants experienced involved
symptoms of pain and stiffness in the neck, head, shoul-
der, arms, and the lower back. Further symptoms were
dizziness, problems with memory and concentration,
headache, depression, loss of sensation in the hands and
arms, loss of sleep, nausea, and irritability. The partici-
pants had their own combination and magnitude of the
symptoms even though they had all been diagnosed as
having chronic WAD. Chronic WAD refers to the fact
that the participants had had their symptoms for at least
3 months. Six participants either had WAD grade II
(neck complaints and musculoskeletal signs) or WAD
grade III (neck complaints and neurological signs), and
one participant had WAD grade IV (neck complaints
and evidence of fracture or dislocation). Table 1 shows
the age of the respondents, and the number of completed
flotation treatments, as well as how long they had had
their chronic WAD. The participants mean age was
40.43 years (SD = 15.74) and they had experienced their
ailments during 2.71 years (SD = 3.31). Two of the par-
ticipants were beginners with regard to flotation-REST
(2 or 3 treatments), and five of them had experienced
between 7 and 15 treatments.
Implementation
The research followed the ethical standards of
the World Medical Association declaration of Helsinki
concerning Ethical Principles of Medical Research
Involving Human Subjects, and the study was approved
by the Ethical Board on Experimentation on Human
Subjects (Forskningsetikkommittén) at Karlstad Univer-
sity, Sweden.
A request for participation in an interview was posed
to 12 persons with chronic WAD who had been treated
Table 1
Age, Duration of Chronic WAD Ailments, and
Number of Flotation Treatments
Duration Number of
Participants Age (in Years) Sessions
1 18 0.5 2
22713
33917
4 40 1.5 9
542210
650312
7671015
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Edebol et al. / Chronic Whiplash-Associated Disorders 483
or were being treated with the flotation-REST tech-
nique at a university in Sweden. Some of them were
beginners, whereas others had been practicing the
flotation-REST treatment for a longer period, but com-
mon to all of them was that the treatment lasted for 45
minutes at least once a week, at the laboratory or at a
cooperating flotation studio near the patient’s living
area. The individuals that thereafter demonstrated inter-
est were contacted by phone, after which the meeting
between participant and interviewer took place at the
laboratory or at another suitable location agreed on with
the participant. The interviews varied from 50 to 80
minutes in length, and were also recorded.
The method of data collection was the semistruc-
tured qualitative interview, which has its emphasis on
the participants’ rich and unique experiences of the
phenomena being studied. An open and flexible inter-
view guide was therefore used during the interview,
which means that the participants’ verbal space had
center stage and the structure of the guide took sec-
ond place. The guide is reduced to a minimum and
follows the story of the participant fully by adding
questions when the participant has described a topic
in depth. The guide consisted of the following ques-
tions: Who are you? How did your whiplash associ-
ated disorder occur? Where is your pain located?
What does whiplash associated disorder mean to
you? How would you describe how it is to float, to
me, who has never done it? Please tell me, is there
anything more you want to tell?
The purpose of asking questions like this is really to
serve narrations made from a unique and personal point
of view, and each interview therefore took a different
direction depending on what the participant experi-
enced as meaningful. All of the interviews originated
from the phenomenological approach that points out
the necessary prevalence of the participants’perspective
at all times. This study did not include the perspective
of a practitioner but had as its mission pointing out
experiences from a purely patient perspective.
All participants received the information that every-
thing would be treated confidentially; i.e., that only the
person who conducted the interview would listen to the
recordings. The participants’integrity had high priority.
To address reliability, the participants were informed
that some of the quotations would be read by two asses-
sors during a credibility test, as well as included in the
presentation of the study, later on. The participants were
also informed that they had the right to terminate the
interview at any time without giving a reason and
without it affecting their treatment. Finally, it was
agreed that the material could be used as a basis for
publication, on the condition that the anonymity of the
participants was guaranteed.
Processing the Data
The Empirical Phenomenological Psychological
Method (EPP method) devised by Gunnar Karlsson
(1995) was used in processing the data. The EPP
method aims to describe structures of meaning and is
based on Giorgi’s (1997) three major points of the phe-
nomenological approach in psychology. The first point
is the reduction of pre-existing theory and knowledge in
favor of whatever is found. The second is the focus on
the description of the material rather than the interpre-
tation, and the third is that the essence of the material is
sought to capture a concentrated structure of the phe-
nomenon. The EPP method entails an analysis in five
stages, where the first step includes the repeated read-
ing of the material to obtain an understanding of the
content. The second step includes techniques for divid-
ing the texts into smaller, so-called “meaning units”
(MUs). This division is not based on grammatical rules
but entirely on the content discovered by the researcher
and where there is a suitable shift of meaning. The
analysis yielded 1,127 MUs. During the third step,
every MU is translated into a higher degree of abstrac-
tion so that the implicit levels of the material become
explicit in the search for the underlying psychological
meaning of the phenomenon. In the fourth step, the
MUs are first organized into categories and then into
“situated structures,” depending on what type of expe-
rience they include. The study generated 28 categories.
The fifth and final step involves shifting from situated
structures to “typological structures” that are presented
in the results and discussion section, with quotations
from the participants.
To control the reliability of the results of the study, a
credibility test for phenomenological analyses was used
(Bergman & Norlander, 2005). Two assessors had the
task, independent of each other, of assigning 50 MUs to
10 of the categories. Each assessor achieved a 74% cor-
respondence rate, which is comparable to earlier
results. The validity of the study was tested by giv-
ing two of the participants access to the 28 cate-
gories. They were then contacted by telephone. The
two participants indicated that the categorization
and descriptions in the categories fit well with their
experiences during the project.
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484 Qualitative Health Research
Results and Discussion
The participants had undergone flotation-REST
treatment a varying number of times and provided
information about stages prior, during, and after the set
of treatments. Throughout the analyses it became obvi-
ous that the experiences previous to the treatment radi-
cally differed from the experiences following the
treatment. The rich experiences prior to the treatment
serve as a background contrasting to the foreground
concerning short-term effects of the flotation-REST
treatment. The results therefore contain two models; the
first model covers the participants’ experiences of the
crises that took place in times prior to the treatment, and
the second model describes the short-term effects of
the flotation-REST treatment in terms of flotation
phases. A linear story about the experienced effects
of the flotation-REST treatment in participants with
chronic WAD appears as the background and adds
depth, the foreground adds light, and the participants’
quotations add illustrations to the story.
The Experience of Chronic WAD
To understand how chronic WAD affected the lives
of the participants prior to the flotation-REST treat-
ment we must think in terms of constant and intense
pain as a central part of life. Some of the participants
described the pain as being like a filter through which
all other impressions and experiences passed:
When I was really ill, then I had real much pain, and
it overshadowed my whole life. It’s like something is
going on all the time, requiring almost all my atten-
tion or sometimes my full attention, but no one else,
neither me nor someone else sees it. Whenever you
want to do the slightest thing, you are already occu-
pied by feeling pain.
Starting with noticing the pain, it is now possible to
look at the model of the crisis that conceptualizes the
experience of chronic WAD prior to the flotation-REST
treatment. One component of the crisis is the conflict
concerning experiences that interior management
strategies cannot meet the outer stress that confronts the
person. Experiences of being limited and unable to do
what one wishes to do are parts of this component:
I bought a motorcycle and I had a motorbike when I
was fifteen, and since then I always wanted to own a
motorcycle again. Two years ago I bought a motor-
cycle and I have hardly been able to ride on it
because I get such pain. Now, I’m about to sell it
again, it just sits there and I don’t want it.
Worrying as to whether one will be able to cope with
the future is also a part of this experience.
Another component of the crisis includes altered
reaction patterns and patterns of behavior that the par-
ticipant does not always have control over and
understanding of. Aggression, frustration, isolation,
and mood swings are examples of such patterns of
behavior that appear unfamiliar and incomprehensible
to the individual: “Like, sometimes I can get so damn
mean, sometimes I am mean towards him, but it’s not
his fault, but how am I going to vent my anger?” The
shock-like and sometimes apathetic condition that
arises because of the accident is included with these
altered reaction patterns. This component is also about
previously used and well-known reaction patterns not
being useful in handling the crisis situation.
A third component consists of altered experiences of
one’s own psychological and social identity. Personal
identity, with self-esteem and acceptance of oneself in
focus, is largely affected. Personal identity is closely
connected to one’s social identity, which is accentuated
when relations with close relatives face new demands.
The need for being reminded of the person you are can
be fulfilled in being with others. Support from and
closeness to other people become important.
The last component of the crisis is the stress mani-
festing itself as, among other things, sleeping problems,
concentration difficulties, irritability, and hypersensitiv-
ity to the surroundings, stress, and demands: “I can’t
focus on anything without mixing everything together.
All that has happened to me in my whole life comes
up.” The stress affects everything, in both a psycholog-
ical and a physiological sense: “I get agitated from the
smallest little thing, and I feel the throbbing, and pres-
sure goes up.” The prescribed medicine—with strong
side effects—also affects the stress level. This compo-
nent of the crisis involves physiological as well as emo-
tional, psychological, and social experiences of chronic
WAD, highlighting the complexity of the disorder. With
this background in mind, the participants’ experiences
of the flotation-REST treatment are brought to the fore-
ground.
Experiences of the Flotation-REST
Treatment
The first—and passing—phase is called “intensifica-
tion” and consists of the experience of increasing pain
as well as difficulties in relaxing in the flotation tank.
“When I started with the floating, I had so much pain
that I didn’t know if I should stay on.” Primarily, this is
a phase with physical key signatures, but it also
includes mental barriers and worries. In time, the strong
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pain dissipates, and the learning process creates secu-
rity and a certainty in the flotation environment that
leads forward in the chain of development. To a certain
degree, the phase is about developing understanding
and a sense of connection to the situation:
The first time I had much pain a few days later. But,
well, I waited about five days and then I laid down
again and I could feel at once that it felt nice when I
laid down.
The next phase is called “vitalization,” and concerns
the physical and mental improvement that gradually
takes place. Reduced pain and stress, as well as
increased knowledge of one’s body and relaxation,
characterizes the vitalization phase. Tension and stiff-
ness diminish and cease successively. The experience
of relaxation and calm is another important part of this
phase:
I feel like I have become better. I haven’t read much
about this, I have mostly tried it and I walk around
telling everybody, “If you are in pain, go and lie
down, it is so nice, it is completely wonderful.” I
think it has become much better after this, I don’t
feel the pain as much as before.
During the flotation process the vitalization phase
recurs, and it carries the development to constantly
healthier levels. This phase is seen as a necessity from
which the beginning of further phases of development is
made possible. It is through the development of the
vitalization phase that much of the distance from the
pain is brought forward. The phases described so far
mostly include experiences perceived on a sensory level.
A change in this type of perception occurs when the
coming phase is, to a large degree, signified by mental,
spiritual, and intuitive impressions and experiences.
“Transcendation” is the phase that entails a further
deepening of the flotation treatment, encompassing
psychological experiences that transcend bodily and
observable barriers. Altered states of consciousness,
developed dream activities, as well as experiences
encompassing fantasy- and picture-rich aspects are
common. To delve deeper into the personal world of
experience and find new contents in these sources is a
part of this phase. In addition, the retrieval of original
nucleus material, such as the experience of being totally
close to oneself, characterizes these transcending
movements. “What I notice is that I feel more like
myself again; it feels soothing.” This phase could be
described as a key, because the flotation treatment
opens up new depths of discovery within the individual.
It is a strengthening development for the person insofar
as contacts are made to other levels of consciousness:
It is almost some kind of mystical time in some way.
The perception of space disappears. I can really get
that feeling that I don’t know which is my body and
which is the thought or the water. I think maybe
that’s why I get that picture, that the floating in some
way touches some very, very deep layer that might
be connected with something we have experienced
as [a] fetus. I know that it...yes,I really believe
that, because I somehow felt that it was like my body
in some way knew something from old. One could
actually imagine that hopefully it could be rather
total relaxation, something very original...it
becomes a wish or longing to feel that condition in
some way, I think when I float there are pictures.
The pictures, dreams, and sensations that express them-
selves are experienced as guiding and enlightening. In
large part, this phase is about trusting that the depths
within oneself exist and function, and that moreover,
they have the ability to reconnect the person to a larger
consciousness and insight. The trust is also about daring
to acknowledge and interpret reality with immediate
instinctive means, and to follow the inklings that arise.
The term “defocusation” alludes to the experience
of the physical pain no longer having center stage as
the feelings and handling of these instead receive the
opportunity to be brought forward. The total isolation
that occurs in the flotation tank makes possible a
form of positive shielding and desensibilization that
promotes the attention toward one’s own emotional
life. A processing of the feelings created as a conse-
quence of the chronic WAD can take over when
insight about and understanding of the situation
develop. The injury does not only affect one in a bod-
ily sense, but also in deep markings in the sphere of
one’s inner emotional life, and for that reason this
phase of nature becomes necessary and important so
as to touch the whole individual. Experiences and
emotions go hand-in-hand with the physical condi-
tion which is tangible when we discuss the phase of
defocusation: “If I just push away those thoughts, I
will stop the bodily relaxation and this liberation
from pain...it’s like, a very...like, it cooperates
very clearly.” The connection between these factors
becomes clearer during the progress of the flotation-
REST treatment, and the more insight is given within
this area, the more a need is created within the person
to treat both aspects of the health condition.
Edebol et al. / Chronic Whiplash-Associated Disorders 485
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486 Qualitative Health Research
The last identified phase, “re-orientation,” describes
the effect of the flotation process, mostly on a cognitive
level, when new trains of thought, attitudes, and prefer-
ences are created. Questions regarding what is impor-
tant, where to put focus, how to move on, what you
want, and on a larger scale, what is meaningful, consti-
tute the hallmark of this phase. A high degree of opti-
mism and thinking about possibilities are characteristic
in this context: “After the floating you can concentrate
and think things through in a better way...how you
feel and what you might want to do, you become more,
you want to do a lot of things afterwards.” To change
focus and see the situation from a wider and more
forward-looking perspective becomes central, and
could be described as a handling strategy, because a
higher degree of distancing toward the disorder devel-
ops. “The floating is liberating, it liberates life, but I feel
that there is a certain perspective to the floating that is
healthy.” The reorientation phase contributes to the
growth of continued vitalization phases as the person is
being prepared for change and positive development.
The reorientation phase creates a place for the spiral of
flotation phases that we will now discuss.
The Spiral of Flotation Phases
The flotation phases could be viewed as a complete
picture of growing circles that, together, form a linear
spiral continuum encompassing movements away from
and over the pain. Through the flotation-REST treat-
ment, the world of experience grows further and the
treatment continually reaches new levels in the psycho-
logical equipment that lives and works within the par-
ticipant. The chain of development moves toward new
altitudes as the vitalization phase is repeated and
strengthens the person anew. The circular development
goes on as the world of experience is able to receive
new impressions and aspects of life. The pain is no
longer experienced as overshadowing, because its posi-
tion changes intact with the spiral development, and
gets reduced to a more limited and manageable area or
disappears. At the same time, the flotation-REST treat-
ment involves the creation of new elements in the world
of experience. The spiral illustrates how the participants
with chronic WAD experience the short-term effects
of the flotation-REST treatment. The effects of the
flotation-REST treatment improves the participants’
experiences described in the concept of the crisis in
terms of pain reduction, stress management, changed
attitudes, renewed coping strategies, openness to per-
ceptions, and the sense of a centered self.
A qualitative study by Åsenlöf, Olsson, Bood, and
Norlander (2007) evaluated whether the combination of
flotation-REST treatment and psychotherapy had any
effect on two patients, one diagnosed with fibromyalgia
and one diagnosed with burnout syndrome depression.
This combined treatment gave very good results in
terms of the participants’ well-being and experience of
meaningfulness and ultimately developed into the “ther-
apeutical spiral.” The results were based on the same
idea as the present study, illustrating the effects of the
flotation-REST treatment as a linear continuum. The
effects of the flotation-REST treatment seem to
strengthen the participant during every treatment ses-
sion, making the participant inclined to seek the treat-
ment again and once more experience the beneficial
effects of the treatment. This spiral development contin-
ues and leads the participant forward in the process of
rehabilitation. In both studies, the participants had expe-
rienced pain relief, well-being, and feelings of meaning
throughout the spiral of flotation-REST treatment.
Many of the sensations and experiences described by
the participants in the present study are because of the
physiological effects of the flotation-REST treatment.
A meta-analysis by van Dierendonck and te Nijenhuis
(2005) evaluated flotation-REST as a stress-handling
technique through 25 studies. The results indicated that
flotation-REST had positive effects in a physiological
sense by way of reduced levels of cortisol and blood
pressure. The flotation-REST technique also increased
the sense of well-being and the ability to perform. An
additional study (Kjellgren et al., 2001) of cases with
chronic pain has shown that the most severe perceived
pain is significantly reduced because of flotation-REST
treatment, while the levels of circulating noradrenaline
(metaboline 3-methoxy-4-hydroxyphenylethylenegly-
col) significantly increased. The study also found that
flotation-REST treatment increased the participants’
optimism, reduced their degree of anxiety and depres-
sion at night, and allowed them to fall asleep more eas-
ily at night. Increased mood and sleep quality, pain
relief, and decreased levels of experienced stress have
been major conclusions in this qualitative study as well.
A study of pain relief during hydrotherapy (Bender
et al., 2005) points out that water immersion during
hydrotherapy induces an increase in methionine-
encephalin plasma levels, and at the same time sup-
presses plasma ß-endorphin, corticotrophin, and
prolactin levels, which all play a part in the experi-
ence of pain relief. Other factors contributing to pain
relief during hydrotherapy are muscle relaxation and
reduced joint swelling (Bender et al., 2005). The
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Edebol et al. / Chronic Whiplash-Associated Disorders 487
effects of pressure and temperature on nerve endings
also take place during flotation-REST treatment,
making these factors important to take into consider-
ation when understanding the pain relief experienced
by the participants of the present study.
Flotation-REST treatment favors the patient in a
physiological sense as well as mentally and cognitively.
The environment in the flotation-REST tank supports
reflection and relaxation to a great extent. In compari-
son to other common treatments of chronic WAD, such
as hydrotherapy, electromagnetic field therapy, radio
wave neurotonomy, cognitive behavior therapy, and
physiotherapy, the ability to benefit mental and cogni-
tive aspects of the patient is high during flotation-REST
treatment. The results of this study, as well as conclu-
sions from other studies of flotation-REST treatment in
cases of chronic pain (Kjellgren et al., 2001), point out
the ability to treat body and mind in a holistic sense.
The integration of body and mind becomes the major
differentiation and unique conceptualization of the
flotation-REST treatment in comparison to other com-
mon treatments of chronic WAD. The complex and
sweeping characteristics of chronic WAD makes the
flotation-REST approach very appropriate.
The present study was the first to evaluate the short-
term effects of the flotation-REST treatment in cases of
chronic WAD, and the qualitative results indicate that
the treatment is a meaningful and beneficial alternative
when treating chronic WAD. Additional studies with
more participants and quantitative data are needed to
evaluate the long-term effects of the flotation-REST
treatment in cases of chronic WAD.
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Hanna Edebol, MSc, is a doctoral candidate in the Department
of Psychology, Karlstad University in Karlstad, Sweden
Sven Åke Bood, PhD, is a lecturer in the Department of
Psychology, Karlstad University in Karlstad, Sweden
Torsten Norlander, PhD, is a professor in the Department of
Psychology, Karlstad University in Karlstad, Sweden.
at Karlstad Universitet on November 10, 2009 http://qhr.sagepub.comDownloaded from
