Reflexology

Reflexology

PEP Topic 
Anxiety
Description 

Reflexology involves applying pressure to areas of the feet and hands, using the thumb, fingers, and hand on specific zones of the feet or hands that reflect other areas of the body. Pressure is applied to specific areas to create a change in the related body part. Reflexology has been evaluated in patients with cancer in the management of pain, anxiety, dyspnea, fatigue, and depression.

Effectiveness Not Established

Research Evidence Summaries

Quattrin, R., Zanini, A., Buchini, S., Turello, D., Annunziata, M.A., Vidotti, C., . . . Brusaferro, S. (2006). Use of reflexology foot massage to reduce anxiety in hospitalized cancer patients in chemotherapy treatment: Methodology and outcomes. Journal of Nursing Management, 14, 96–105.

doi: 10.1111/j.1365-2934.2006.00557.x
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Study Purpose:

To reduce anxiety caused by chemotherapy (not the diagnosis)

Intervention Characteristics/Basic Study Process:

The intervention was reflexology foot massage in hospitalized patients undergoing their second or third cycle of chemotherapy (30-minute foot massage on both feet by an RN student). The Spielberger State-Trait Anxiety Inventory was administered before and after reflexology and 24 hours post-reflexology.

Sample Characteristics:

The study reported on a sample of 30 patients: 15 in the control group and 15 in the reflexology foot massage group.

Setting:

Italian research hospital

Measurement Instruments/Methods:

Spielberger State-Trait Anxiety Inventory

Results:

There was an average decrease of 7.9 points on the state-anxiety scale in the treatment group (p < 0.0001) after the short time frame (immediate decrease in anxiety).

Limitations:

  • The study had a small sample size.
  • The sample was not randomized, and patients were not categorized by cancer diagnosis, stage, or presence of metastasis.
  • The study used a specially trained reflexology practitioner.

Sharp, D.M., Walker, M.B., Chaturvedi, A., Upadhyay, S., Hamid, A., Walker, A.A., . . . Walker, L.G. (2010). A randomized, controlled trial of the psychological effects of reflexology in early breast cancer. European Journal of Cancer, 46, 312–322.

doi: 10.1016/j.ejca.2009.10.006
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Study Purpose:

To evaluate the effects of reflexology in comparison with two comparator interventions (reflexology and massage) on cancer-related quality of life, relaxation, mood, and adjustment in women with newly diagnosed early-stage breast cancer

Intervention Characteristics/Basic Study Process:

Women were randomized to one of three interventions:

  • Intervention 1: reflexology plus self-initiated support (SIS)
  • Intervention 2: scalp massage plus SIS (comparator intervention – identical amount of physical and social contact)
  • Intervention 3: SIS (comparator intervention – treatment as usual; this was the control group).

Patients receiving reflexology or massage received eight one-hour sessions at weekly intervals for eight weeks, beginning seven weeks after surgery. Patients were assessed by a clinical and research specialist nurse (blinded to treatment allocation) before randomization (week 6 post-surgery), 18 weeks after surgery (primary end point 1), and 24 weeks after surgery (secondary end point). Seventy-five percent of women received all eight sessions of reflexology, and 75.4% received all eight sessions of massage.

Sample Characteristics:

  • The study reported on a sample of 183 patients: 60 in the reflexology group, 61 in the massage group, and 62 in the SIS group.
  • Mean patient age was 59.37 ± 10.46 (range = 32–81) in the reflexology group, 57.70 ± 10.12 (range = 36–76) in the massage group, and 59.36 ± 10.23 (range = 36–77) in the control group.
  • All patients were diagnosed with early-stage breast cancer; the sample was 100% female.
  • Patients were randomized six weeks after breast surgery (not controlled for treatment type). It appears that most patients were receiving chemotherapy, radiation therapy, or both, but the authors were unable to determine exactly from the sample description.

Setting:

  • Multisite
  • Outpatient setting
  • United Kingdom

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

A randomized controlled trial design was used.

Measurement Instruments/Methods:

  • Functional Assessment of Cancer Therapy (FACT-B)
  • Trial Outcome Index (TOI)
  • Mood Rating Scale (MRS)
  • Hospital Anxiety and Depression Scale (HADS)
  • Complementary Therapies Questionnaire (CMQ)
  • Structured Clinical Interview for DSM-IV-TR (SCID)

Results:

There were no significant differences between groups on any measure or demographic variable at baseline. At the primary end point (week 18), TOI scores for the three groups differed significantly: massage patients had significantly higher scores on the TOI (indicating a better quality of life) than those receiving SIS. The difference existed only between massage and SIS. There were no differences among groups in self-reported quality of life as measured by FACT. MRS scores at the primary end point showed that massage and reflexology patients were significantly more relaxed than those randomized to SIS, and total MRS scores for reflexology and massage patients were significantly higher than for SIS patients. At this end point, massage patients were significantly more easygoing than either reflexology or SIS patients. Scores on HADS anxiety and depression did not differ significantly between the three groups. At the second end point (week 24), reflexology patients were significantly more relaxed than SIS patients measured by TOL and MRS. Scores on HADS anxiety and depression did not differ significantly between the three groups.

Conclusions:

The authors concluded this was a well-controlled and rigorous study with an adequate sample size. Overall, however, there was low psychiatric morbidity in this sample, and despite the high compliance with the interventions (reflexology and massage), there were really no significant differences in the two end points in the depression scores.

Limitations:

  • The study did not include an appropriate control group.
  • The study design lacked an attentional control.

Nursing Implications:

Findings do not support effectiveness of reflexology for reduction of depression or anxiety.

Stephenson, N.L., Swanson, M., Dalton, J., Keefe, F.J., & Engelke, M. (2007). Partner-delivered reflexology: Effects on cancer pain and anxiety. Oncology Nursing Forum, 34, 127–132.

doi: 10.1188/07.ONF.127-132
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Study Purpose:

To test the effectiveness of reflexology delivered by partners in patients with cancer 
 

Intervention Characteristics/Basic Study Process:

An initial reflexology session of 30 minutes was provided in the hospital setting. The session included relaxing techniques, 15 minutes of reflexing areas of the feet corresponding to areas of the patient’s reported pain and body parts where cancer or pain was located. The final five minutes were used to reflex the entire area of the feet. Partners were taught how to perform a reflexing protocol and provided with associated written materials. Partners practiced the technique on the investigator or the patient and were given feedback on the technique. Signs and symptoms of deep vein thrombosis were reviewed to alert partners to avoid foot reflexology in that situation. Patients in the control group received usual care plus special attention for 30 minutes, consisting of reading a selection of the patient’s choice to the patient. Study data were obtained pre- and postintervention.

Sample Characteristics:

  • The study reported on a sample of 86 patients.
  • Mean patient age was 60 years (SD = 12.1 years) in the experimental group and 56 years (SD = 24.4 years) in the control group.
  • The sample was 51% female and 49% male.
  • The most prevalent types of cancer were lung, breast, colorectal, head and neck, and lymphoma.
  • Of the total sample, 66% had a high school education or less, and 50% had an income less than $20,000.
  • Baseline pain was 3.2 in the experimental patients and 4.5 in the control patients. Baseline anxiety was 5.0–5.6 (10-point scales).

Setting:

  • Multisite
  • Inpatient setting
  • North Carolina

Phase of Care and Clinical Applications:

  • Patients were undergoing multiple phases of care.
  • The study has clinical applicability for end-of-life and palliative care.

Study Design:

A randomized controlled trial design was used.

Measurement Instruments/Methods:

  • Visual Analog Scale for Anxiety
  • Brief Pain Inventory
  • Short-Form McGill Pain Questionnaire

Results:

In the total sample, there were no significant differences between groups in pain outcome measures. In patients with higher baseline pain levels (≥ 5), significant differences were found in favor of the reflexology group in analysis of variance (p = 0.001, eta2 for effect size = 0.12). Patients in the reflexology group had significant reduction in anxiety, with a 62% reduction from baseline to postintervention in those receiving reflexology versus 23% reduction in controls. Among those with higher levels of anxiety (≥ 5), significant differences were found in favor of reflexology (p = 0.001, eta2 = 0.13).

Conclusions:

Partner-delivered reflexology was associated with reduction in pain and anxiety compared to controls. The intervention appeared to be most effective in patients with higher levels of pain and anxiety.

Limitations:

  • The study had a small sample, with less than 100 participants.
  • The attentional control used was reading, rather than some use of touch. It is unclear if the specific technique of reflexology or touch was responsible for results observed.
  • Limited demographic information was provided, so generalizability is not clear.
  • The intervention was a single time point with pre- and post-measures. Longer term results or repeated use effects were not explored. The study was initially designed to include long-term follow-up after hospital discharge; however, attrition was so severe that this aspect of the research was dropped.
  • There was no blinding, so there are associated risks of bias.
  • No information was provided about medication use or any changes or differences between groups in overall pain management interventions.

Nursing Implications:

Findings suggest that foot reflexology can be helpful for patients with cancer in reducing anxiety and perception of pain in the short term. Study findings suggest that partners can be taught to provide this type of intervention. Addition of partner-delivered reflexology might be a useful adjunct for anxiety and pain control; however, trained individuals need to be available to provide the teaching or the actual intervention.  Involvement of caretakers in patient care with this type of approach might be a useful way to empower patients and caregivers.

Tsay, S.L., Chen, H.L., Chen, S.C., Lin, H.R., & Lin, K.C. (2008). Effects of reflexotherapy on acute postoperative pain and anxiety among patients with digestive cancer. Cancer Nursing, 31(2), 109–115.

doi: 10.1097/01.NCC.0000305694.74754.7b
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Study Purpose:

To investigate the effects of foot reflexology on pain and anxiety in patients undergoing surgery for digestive cancer

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to the intervention group or a control group that received usual care. The intervention consisted of 20 minutes of foot reflexology using a standard protocol. A nurse certified to deliver this treatment provided it on day 2 after surgery, between one and three hours after the patient had received a dose of pain medication. Pain and anxiety were assessed at baseline and on postoperative day 5. A research assistant blinded to the randomization collected data. In the intervention group, pain was assessed before and after the intervention.

Sample Characteristics:

  • The sample was composed of 62 patients.
  • Mean patient age was 59.8 years (SD = 14.7 years).
  • Of all patients, 52.5% were female and 47.5% were male.
  • Patients had hepatocellular and gastric cancer. The types of surgeries performed were gastrectomy, hepatic lobectomy, or segmentectomy.
  • Of all patients, 77% were married and 54% had more than a high school education.
  • Patients with a history of chronic pain were excluded from the sample.

Setting:

  • Single site
  • Inpatient
  • Taiwan

Study Design:

Randomized single-blind controlled trial

Measurement Instruments/Methods:

  • Short-Form McGill Pain Questionnaire
  • Visual analog scale (VAS), to assess pain
  • Hospital Anxiety and Depression Scale (HADS)
  • Measures of Demerol use per day

Results:

  • There were no differences between groups regarding main effects on pain or anxiety. However, when time was added as a factor in statistical analysis, a significant difference between groups developed. Time-dependent changes showed that perceived pain decreased more in the intervention group (p < 0.0001) than in the control group. Pain scores on the VAS were lower in the intervention group over time (p < 0.0001).
  • The pain score immediately after the intervention declined by a mean difference of 12.09 mm (p < 0.001).
  • There were no main effects relating to anxiety; however, time-dependent changes in anxiety declined more in the intervention group than in the control group (p < 0.0001).
  • Overall pain and anxiety declined in both groups over time. In the intervention group, the average daily dosage of Demerol was significantly lower (p = 0.015) than in the control group. Perceived pain was correlated with anxiety (r = 0.43, p = 0.001).

Conclusions:

Foot reflexology as provided in this study may be helpful in reducing postoperative pain.

Limitations:

  • The study had a small sample size, with fewer than 100 patients.
  • The study had a risk of bias due to no appropriate attentional control group. Although the authors described this as a double-blind study, patients who received the intervention knew that they were receiving it and those who did not receive it knew that they did not. Additional attention from the intervention or patient expectations associated with the intervention may have affected findings. Without an attentional control, the existence and extent of these effects are unclear.
  • The study was done in a single country. Responses may not apply to all cultural groups.

Nursing Implications:

This type of intervention may be helpful in managing pain in postoperative patients. The relationship between anxiety and pain suggests that efforts to reduce anxiety may affect patients’ perceptions of pain.

Wyatt, G., Sikorskii, A., Rahbar, M. H., Victorson, D., & You, M. (2012). Health-related quality-of-life outcomes: a reflexology trial with patients with advanced-stage breast cancer. Oncology Nursing Forum, 39, 568–577.

doi: 10.1188/12.ONF.568-577
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Study Purpose:

To evaluate the safety and efficacy of reflexology.

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to one of three groups:  reflexology, lay foot manipulation, or the control. Certified reflexology providers administered the reflexology intervention in four weekly, 30-minute sessions. Foot manipulation providers were laywomen trained in the procedure. The laywomen delivered foot manipulation according to the relexology schedule. The control group received standard care. Study data were collected at baseline and at 5 and 11 weeks after randomization. Reflexologists and foot manipulation providers collected data after sessions at the planned time points.

Sample Characteristics:

  • The study was comprised of 243 women with breast cancer.
  • Mean age was 55.7 years.
  • Most patients had stage III or IV breast cancer, and 79.67% had metastatic disease.
  • The majority (83%) of patients were Caucasian, 65% were married or partnered, and 35% were employed. Educational level varied across the groups.
  • Patients were excluded if they were in hospice care at the time of study entry.

Setting:

  • Multisite
  • United States

Phase of Care and Clinical Applications:

The study has clinical applicability for late effects and survivorship.

Study Design:

The study was a three-group, single-blind, randomized, controlled trial.

Measurement Instruments/Methods:

  • Short Form Health Survey (SF-36) Physical Functioning Subscale
  • Functional Assessment of Cancer Therapy–Breast (FACT-B)
  • Brief Fatigue Inventory (BFI)
  • Brief Pain Inventory (BPI)
  • State-Trait Anxiety Inventory (STAI)

Results:

At baseline, scores regarding anxiety and depression, according to the Center for Epidemiologic Studies Depression Scale (CESD), differed significantly (p < 0.01) across study groups. No differences were found regarding quality of life and symptoms of depression, anxiety, pain, or nausea. Those receiving reflexology reported lower levels of dyspnea than did the other two groups (p ≤ 0.02). Patients getting foot manipulation from laywomen had lower fatigue scores than did the controls (p < 0.01). Further analysis showed that the effect on fatigue was mediated by changes in dyspnea. Eleven percent of those in the foot manipulation group and 10% of those in the reflexology group did not complete all the sessions. The intervention had no adverse effects.

Conclusions:

The findings suggested that reflexology may improve the symptoms of dyspnea and that foot manipulation may help reduce fatigue in women with advanced-stage breast cancer. The authors noted no effect of reflexology or foot manipulation on pain, anxiety, symptoms of depression, or nausea.

Limitations:

  • The study had important baseline sample and group differences.
  • The study had a risk of bias due to the lack of blinding.
  • The findings were not generalizable; the study was underpowered in regard to detecting planned differences in patient outcomes.

Nursing Implications:

The findings did not indicate that reflexology and foot manipulation affected pain, anxiety, symptoms of depression, or nausea among women with advanced breast cancer. The study demonstrated that these interventions are safe for the type of patients who participated. Reflexology and foot manipulation are low-risk interventions that may be helpful to some patients. Laypeople and caregivers could be taught these techniques, which may provide a meaningful way for these people to be involved in symptom management.


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