Written by Helen Cooke and the CAM-Cancer Consortium.
Updated October 24, 2016

Reflexology

Abstract and key points

  • Reflexology employs manual pressure to specific areas of the body, usually the feet, which are thought to correspond to internal organs with a view of generating positive health effects.
  • Evidence for improvements in pain, quality of life, anxiety and breathlessness are limited by methodological shortcomings of trials
  • Reflexology has a good safety record.

Reflexology is a supportive treatment modality employing manual pressure to specific areas of the body, usually the feet (occasionally the hands), which are thought to correspond to internal organs.

Reflexologists suggest that by palpating the feet they can influence specific organ functions, reduce stress, eliminate toxins, rebalance the body’s energy, improve circulation, or promote metabolic homoeostasis.

Evidence from four systematic reviews including eleven individual trials in cancer patients, four additional randomised controlled trials and one non-randomised clinical trial indicate improvements in pain, quality of life, anxiety and breathlessness. Due to methodological limitations such as  lack of blinding and variation between trials in interventions, controls and outcomes measured it is, however, not possible to draw conclusions about the effectiveness of reflexology for people with cancer. 

Reflexology has a good safety record.

What is it ?

Reflexology is a treatment modality employing manual pressure to specific areas of the body, usually the feet (occasionally the hands), which are thought to correspond to internal organs, with a view to generating positive health effects 1.

Application and dosage

The therapist takes a case history during the first session, which includes asking about patients’ presenting condition/symptoms and any medications they are receiving. Reflexology is usually received in a semi-upright position or on a reclining chair or couch. The treatment may include some light massage strokes and gentle stretches. Reflexology sessions last for about 30 minutes to one hour. A course of several treatments is often recommended by the practitioner.

History/providers

Although reflexology was widely used in the Far East for centuries and is thought to have originated as long as 5000 years ago, a form of technique referred to as ‘Zone Therapy’ first appeared in Europe in the late 16th century. American ear, nose and throat specialist Dr. William Fitzgerald introduced it as a therapy in the early 20th century after having observed that application of pressure to certain areas of patients’ feet or hands resulted in sensations in a corresponding area of the body. It was further developed by nurse and physiotherapist Eunice Ingham, who introduced it in Europe in the early 20th century. She created a map of 'reflexes' on the feet and hands, which she stated corresponded to different glands, organs and body 2.

Claims of efficacy/mechanism of action/alleged indications

Reflexologists work with the concept that the sole of the foot is a map which represents the entire body. By palpating the foot, areas of tenderness or "grittiness" are purported to indicate an imbalance in the corresponding organ 1. Reflexologists purport to be able to detect subtle changes in specific points on the feet and consider that using various techniques of massage and pressure to these points may affect the corresponding organ, organ system or body 3.

Possible mechanisms of action that have been suggested include a theory of energy mechanisms, suggesting reflexology points are linked to internal organs and structures by energy channels which become blocked in the event of illness and which are re-opened through reflexology 4; a neuromatrix pain theory, where reflexology is believed to relieve pain by transmitting afferent impulses and closing the neural gates in the dorsal horn of the spinal cord, thus blocking pain transmission 4; a lactic acid theory, where it is thought that lactic acid deposited as microcrystals in the feet are crushed by the application of pressure/massage which thereby allows for the free flow of energy 5; a relaxing effect which contributes to relieving tension and stress affecting the autonomic response, which, in turn, affects the endocrine, immune, and neuropeptide systems 5; and finally a theory suggesting that reflexology is simply a method of showing care and concern for patients 5.

Prevalence of use

A European Survey of cancer patients reported that 3.9 % of respondents used some form of manipulative or body-based method (included massage, reflexology and other methods) after their cancer diagnosis 6. 4.5% of respondents were using some form of energy therapy before their diagnosis. The exact prevalence of the use of Reflexology for cancer patients is unknown.

Legal issues

Regulation and registration of complementary therapists varies across Europe. In the UK reflexologists may practice under Common Law and do not have to be registered with one of the federal bodies. Many practitioners have however decided to join a system of voluntary self-regulation. For more information about legal issues for reflexologists in Europe please access the Reflexology in Europe Network 19.

Costs and expenditures

A reflexology session costs between 40-70 Euro. A course of treatment often consists of six to eight sessions.

Does it work ?

In summary, although some of the existing literature indicates improved pain, quality of life, anxiety and breathlessness in cancer patients who receive reflexology, most of these studies have considerable methodological limitations. Such limitations were also pointed out by the authors of a narrative review aiming to understand the state of research on massage (including reflexology) for cancer patients in order to propose improved research designs for future studies.7 Evidence is therefore insufficient to document any effectiveness of reflexology. Blinding is associated with considerable difficulties in reflexology research. It is therefore challenging to test the efficacy of this treatment modality.

Systematic reviews

Four systematic reviews including 11 individual trials were assessed for this summary (of the 22 reflexology trials included in the reviews overall, six of the trials did not involve cancer patients and five overlapped).  All studies had significant methodological limitations. It is, based on these reviews, not possible to draw conclusions about the efficacy or effectiveness of reflexology.

A systematic review by Lee et al (2015) investigated the effects of massage therapy on pain in any type of cancer.11 RCTs in English, Chinese and Korean were included if they used the outcome measures Visual Analogue Scale, Brief Pain Inventory, Numeric Rating Scale and Present Pain Inventory. Of the twelve included RCTs, four (n=152) assessed foot reflexology. Results indicated that foot reflexology was significantly more effective in all four studies (standardized mean difference −1.46 [95% CI −2.45 to −0.47];P=0.004). Foot reflexology appeared to be more effective than body or aroma massage. However, methodological shortcomings such as possible selection bias and the small number of long-term studies render this evidence insufficient to suggest that reflexology is an effective long-term care option for patients with cancer pain.

A systematic review (2011) examining the effectiveness of reflexology for treating any medical condition, included five reflexology trials for people with cancer.8 Three trials suggested positive results for quality of life, anxiety and pain and two failed to show convincingly that reflexology is an effective treatment for mood and other cancer-related symptoms. This systematic review did not find convincing evidence that reflexology has health benefits beyond a placebo response for treating any medical conditions.

A systematic review (2010) assessed the effectiveness of reflexology as a symptomatic treatment for breast cancer.9 Four trials met the inclusion criteria. One large randomised controlled trial (RCT) showed a significant difference in quality of life and mood when compared with self-initiated support. Three non-randomised controlled clinical trials suggested favourable effects of reflexology for pain, nausea but were at high risk of bias. The review concluded that collectively the existing evidence does not convincingly show reflexology to be effective for breast cancer care.

Wilkinson et al. (2008) carried out a systematic review based on 5 studies examining the effectiveness of reflexology for symptom relief in patients with cancer.10 The authors concluded that, due to methodological limitations of the included publications, it was not possible to determine the effectiveness of reflexology in alleviating physical and psychological symptoms or in improving quality of life, nor to identify adverse side effects. The review was carried out according to Cochrane principles for systematic reviews.  

Controlled clinical trials

Four further RCTs15-18 including one pilot RCT16 and one non-randomised trial12 have been published that were not included in the above reviews. For details of these trials please see table 1.

A large (n=385) RCT found significant improvements in physical functioning for the reflexology group compared to the control group, including a reduction in the severity of dyspnoea.15 This study did not find any effectiveness for other health related quality of life indices measured including pain, anxiety and depression for women with advanced stage breast cancer. The reliability of the results is affected by a lack of blinding.

Two studies which demonstrated reductions in pain and anxiety have considerable methodological limitations.12,16 One of the studies12 was small (n=30) and lacked randomisation and the other was a pilot,16 also with a small (n=18) sample size. This small pilot showed both reflexology and Swedish massage (to lower extremities) to be associated with significant changes to salivary cortisol levels, with a slight advantage for reflexology.16

Another RCT which compared the effectiveness of reflexology and aromatherapy, found both interventions to be effective for patients’ self-reported problems/concerns.17 Within group comparisons revealed that both reflexology and massage were associated with statistically significant changes in salivary cortisol and pain. When post-treatment values were compared to the baseline values a slight advantage was indicated for Reflexology

An RCT demonstrated that scalp massage (the active control group), but not reflexology induced a range of potentially beneficial immunological changes.18 

Is it safe ?

Adverse events

Some authors have reported adverse effects including fatigue and changes in kidney or bowel function 1.

Contraindications

Anecdotal evidence suggests that the following may be contraindications: Gout, leg ulcers, peripheral vascular disease, deep-vein thromboses, infections, bruising, wounds and lymphoedema 13.

Interactions

It has been purported that interaction with insulin is conceivable, dues to the possible stimulation of the pancreas during a treatment session 1,2. There are no known reports of this interaction occurring.

Warnings

Although reflexology has a good safety record, there is concern that some reflexologists with inadequate competence may attempt to diagnose conditions as part of their treatment package 14. Reflexologists do however state that they are not trained to diagnose diseases or to attempt to treat or cure specific medical conditions 2.

Evidence tables

Please view the PDFs listed below for details of the systematic reviews and/or controlled clinical trials included in this summary.

Table 1: Controlled clinical trials of reflexology for cancer

Citation

Helen Cooke, CAM-Cancer Consortium. Reflexology [online document]. http://cam-cancer.org/The-Summaries/Manipulative-body-based/Reflexology. October 24, 2016.

Document history

Last update and revision in October 2016 by Helen Cooke.
Fully revised and updated in September 2014 by Helen Cooke.
Fully revised and updated in June 2012 by Helen Cooke.
Summary first published in March 2011, authored by Helen Cooke.

References

  1. Ernst E, Pittler MH, Wider B and Boddy K. Oxford Handbook of Complementary Medicine. Oxford University Press (2008). ISBN 978-0-19-920677-3.
  2. Pitman, V and MacKenzie, K. Reflexology: A practical approach (1997). Stanley Thornes. ISBN: 0-7487-2867-8.
  3. Association of Reflexologists UK website: http://www.aor.org.uk/, accessed 10 August 2016.
  4. Tsay S, Chen H, Chen S, Lin H, Lin K. Effects of reflexotherapy on acute postoperative pain and anxiety among patients with digestive cancer. Cancer Nursing. 2008; 31(2): 109-15.
  5. Stephenson NL, Weinrich SP, Tavakoli AS. The effects of foot reflexology on anxiety and pain in patients with breast and lung cancer. Oncology Nursing Forum. 2000; 27(1):67-72.
  6. Molassiotis A et al. Use of complementary and alternative medicine in cancer patients: a European survey. Annals of Oncology 2005; 16: 655-653
  7. Myers CD, Walton T, Bratsman L, Wilson J, Small B. Massage modalities and symptoms reported by cancer patients: narrative review. J Soc Integr Oncol. 2008; 6(1):19-28.
  8. Ernst E, Posadzki P, Lee MS. Reflexology: an update of a systematic review of randomised clinical trials. Maturitas 2011; 68(2):116-120.
  9. Kim JI, Lee MS, Kang JW, Choi dY, Ernst E. Reflexology for the symptomatic treatment of breast cancer: a systematic review. Integrative Cancer Therapies 2010; 9(4):326-330.
  10. Wilkinson S, Lockhart K, Gambles M, Storey L. Reflexology for symptom relief in patients with cancer. Cancer Nursing. 2008; 31 (5): 354-62. 
  11. Lee SH, Kim JY, Yeo S, Kim SH, Lim S. Meta-Analysis of Massage Therapy on Cancer Pain. Integrative cancer therapies. 2015;14(4):297-304.
  12. Quattrin R, Zanini A, Buchini S, Turello D, Annunziata MA, Vidotti C, Colombatti A, Brusaferro S. Use of reflexology foot massage to reduce anxiety in hospitalized cancer patients in chemotherapy treatment: methodology and outcomes. J Nurs Manag. 2006; 14(2): 96-105.
  13. Berenson SC. Management of cancer pain with complementary therapies. Oncology (Williston Park) 2007; 21(Suppl 4):10-22.
  14. White AR, Williamson J, Hart A, Ernst E. A blinded investigation into the accuracy of reflexology carts. Complement Ther Med. 2000; 8(3):166-172.
  15. Wyatt GA. Sikorskii MH, Rahbar D, Victorson and You M. Health-related quality-of-life outcomes: a reflexology trial with patients with advanced-stage breast cancer. Oncology nursing forum. 2012 39, 568-577 DOI: 10.1188/12.ONF.568-577
  16. Hodgson NA and Lafferty D. Reflexology versus Swedish Massage to Reduce Physiologic Stress and Pain and Improve Mood in Nursing Home Residents with Cancer: A Pilot Trial. Evidence-Based Complementary and Alternative Medicine. 2012. Article ID 456897, 5 pages, 2012. doi:10.1155/2012/456897
  17. Dyer J, Thomas K, Sandsund C and Shaw C. Is reflexology as effective as aromatherapy massage for symptom relief in an adult outpatient oncology population? Complement Ther Clin Pract 2013 19(3): 139-146.
  18. Green VL, Alexandropoulou A, Walker MB, Walker AA, Sharp DM, Walker LG and Greenman J. Alterations in the Th1/Th2 balance in breast cancer patients using reflexology and scalp massage. Experimental and therapeutic medicine 2012. 1, 97-108 DOI: 10.3892/etm_00000018
  19. Reflexology in Europe Website: http://reflexology-europe.org Accessed 3rd October 2016