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Flotation-Restricted Environmental Stimulation Technique

A Proposed Therapy for Improving Performance and Recovery
in Special Forces Operators — A Narrative Review

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Reginald O’Hara, PhD *; Lewis Sussman, PsyD ;
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Riley Sheehan, PhD ; Benjamin Keizer, PhD ; Jeffrey Tiede, MD 5
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ABSTRACT
The flotation-restriction environmental stimulation technique effortless, simulating a weightless sensation; therefore, the neu-
(FR) may have utility as a recovery tool for improving per- romuscular system receives respite, as well. Lilly reported that
formance in elite competitive athletes and Special Operations FR likely dampens the arousal of the central nervous system
Forces Operators (SOs). Studies suggest that FR may amelio- by eliminating external stimuli and reducing the gravitational
rate various neurophysiological disorders and improve perfor- effects on the body, leading to the attenuation of psychophys-
mance in recreational and elite athletic populations. We sought iological stress. 4
to understand whether there is evidence to support the use of
FR to enhance physiological and psychological performance Researchers reported that FR might aid in the treatment of
parameters in the SO population and to provide postulations interrelated health disorders, such as chronic pain, hyperten-
as to the mechanisms of action of FR therapy. We performed sion, insomnia, rheumatoid arthritis, anxiety, and depression,
an online literary search of publications dating from 1982 to as well as improvement in complex skill acquisition. Re-
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2021 and identified 34 sources addressing the aims, depend- cently, FR has also been used by elite competitive athletes as a
ing on population and condition or conditions, being treated. technique for recovering from the physical and mental stresses
The reported physiological and psychological benefits of FR incurred during high-intensity (load) performance training. 4,7,8
range from immediate to lasting 4 months. Overall, eight to Various stress-related measures have also been reported to
twelve FR treatment sessions of from 40 to 90 minutes each improve following FR, such as those of brain waves (e.g., al-
may provide variable long-term benefits. The associated syn- pha, theta), and reductions in epinephrine levels, renin activ-
ergistic benefits of FR may be attributed to its thermal, chem- ity values, resting heart rate, blood pressure measurements,
ical, and mechanical effects but deserve further exploration. adrenocorticotropic hormone levels, and urinary and plasma
Based on the current evidence, FR may serve as an effective cortisol levels. 3,4,9 Positive outcomes from FR in healthy par-
performance-recovery therapy for improving pain, sleep, and ticipants and those with chronic stress-related conditions are
performance measures (e.g., marksmanship and physical per- well documented in the literature. 1,2,5,10-12 The benefits of FR
formance) in trained, untrained, and healthy adults. Future re- are promising, but additional exploration is needed, especially
search focusing on FR as a unimodal recovery intervention is to demonstrate its value in augmenting performance in elite
warranted in a specialized group of SOs. athletic and specialized military populations.

Keywords: adult; humans; pain; sleep; exercise; athletes; physi- SOs endure physically and psychologically demanding train-
cal functional performance ing and deployment cycles throughout their careers. Hence,
this narrative review seeks to understand whether there is ev-
idence to support the use of FR to enhance physiological and
psychological performance parameters in the SO population
Introduction
and to provide postulations as to the mechanisms of action of
FR therapy was invented in 1954 by John Lilly, with the cen- FR therapy.
tral focus of treating various psychological disorders. FR is
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designed to promote deep relaxation and reduce the effects Methods
of environmental stressors. The participant floats supine in a
hypersaline solution, at skin temperature, in a controlled en- Search Strategy
vironment that blocks all other stimulation. The experience is This review was conducted according to the general frame-
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calibrated to minimize sensory signals from visual, auditory, work of narrative reviews outlined by Ferrari. Peer-reviewed
olfactory, gustatory, thermal, tactile, vestibular, gravitational, primary and secondary articles concerning flotation-REST
and proprioceptive channels to promote deep relaxation and (restricted environmental stimulation technique) were identi-
a mind-body connection. Water temperature is adjusted so fied by searching PubMed (1982 to 2021), and the Cochrane
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that air, water, and body match seamlessly. Because of the Library (Oct 1982–Oct 2021) through the advanced search
high specific gravity of the Epsom salt (i.e., magnesium sul- builder in PubMed and search manager in the Cochrane Li-
fate) solution, the body is extremely buoyant, and floating is brary. The key search terms for each database were “adults,”

*Correspondence to reginald.b.ohara.civ@mail.mil
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1 Dr Reginald O’Hara is chief, Biochemistry Services Division, William Beaumont Army Medical Center, Fort Bliss, TX. Dr Lewis Sussman (re-
tired) was formerly director of the Functional Restoration Program at the CFI. Dr Riley Sheehan, Dr Benjamin Keizer, and Dr Jeffrey Tiede
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are affiliated with the Center for the Intrepid, Brooke Army Medical Center, Joint Base San Antonio–Fort Sam Houston. Dr Riley Sheehan is
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additionally affiliated with the Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD.
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