Reflexology | Cam-Cancer

Reflexology

Abstract and key points

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 is available from four systematic reviews including eleven individual trials in cancer patients, twelve additional randomised controlled trials and three non-randomised clinical trials.

It indicates improvements in pain (n=11), nausea and vomiting (n=2) but the findings are limited by methodological shortcomings of the controlled clinical trials.

The evidence for quality of life is not consistent; three of the assessed eleven controlled clinical trials report no improvements and all studies have methodological limitations.

Findings from one large good-quality RCT report positive results for healthcare utilization and work-related productivity including symptom severity and interference in cancer patients receiving reflexology.

Further individual trials report improvements in physical outcomes including dyspnoea, as well as fatigue/sleep.

No positive results have been reported by one small pilot for neuropathy and one comparison trial of reflexology and aromatherapy on immune function.

Reflexology has a good safety record.

Document history

Last updated and revised in March 2019 by Ava Lorenc.
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.

Citation

Ava Lorenc, Helen Cooke, CAM-Cancer Consortium. Reflexology [online document]. March 2019.

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 effects1.

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 body2.

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 organ1. 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 body3.  Cohort/qualitative research suggests that breast cancer patients receiving reflexology are mostly seeking help with psychological and emotional concerns (45%) or physical concerns (37%), and report improvements in poor energy levels, hot flushes and sweats4 and a reconnection with their ‘self’5.

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 reflexology6; 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 transmission6; 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 energy7; a relaxing effect which contributes to relieving tension and stress affecting the autonomic response, which, in turn, affects the endocrine, immune, and neuropeptide systems7; and finally a theory suggesting that reflexology is simply a method of showing care and concern for patients7.

Prevalence of use

No recent prevalence data are available. Older surveys show  that of people with cancer in Wales 3.3% had used reflexology in the past 12 months8 and a European Survey reported that 3.9 % of respondents used some form of manipulative or body-based method (included massage, reflexology and other methods) after their cancer diagnosis9.

Legal issues

Regulation and registration of reflexologists varies across Europe. In the UK reflexologists may practise 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 Network31.

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?

Palliative/supportive care

Four systematic reviews11-14 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 included studies had significant methodological limitations.  All four systematic reviews were good quality, with adequate sources searched, and independent article selection and data extraction.

The most recent systematic review by Lee et al published in 201514 included any type of massage for cancer pain and found 4 studies of reflexology, three of which were high quality. They found no evidence of publication bias and performed a meta-analysis. A systematic review by Ernst et al published in 201111 covered any medical condition, four studies were for cancer. A further review by Kim et al published in 201012 included breast cancer patients only and found four studies (only one RCT). A 2008 review by Wilkinson et al13 including 5 RCTs was carried out according to Cochrane principles for systematic reviews but is now rather out of date. Thirteen further studies15-18,21-29 including two pilot RCTs16,22 and three non-randomised trials15,17,18  have been published since/ were not included in the above reviews. For details of these trials please see table 1.

Some of the existing literature indicates improvements in pain (n=11), nausea and vomiting (n=2) but all the findings are limited by methodological shortcomings of the controlled clinical trials. The evidence for quality of life is not consistent; three of the assessed eleven controlled clinical trials report no improvements and all studies have methodological limitations.

Findings from one large good-quality RCT report positive results for healthcare utilization and work-related productivity including symptom severity and interference in cancer patients receiving reflexology.  Further individual trials report improvements in physical outcomes including dyspnoea, as well as fatigue/sleep.

No positive results have been reported by one small pilot for neuropathy and one comparison trial of reflexology and aromatherapy on immune function.

Pain

The systematic review by Lee et al (2015) investigated the effects of massage therapy on pain in any type of cancer14. 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.

The 2011 systematic review by Ernst et al examining the effectiveness of reflexology for treating any medical condition, included five reflexology trials for people with cancer11. One trial suggested positive results for pain.

The 2010 systematic review by Kim et al (four trials) assessed the effectiveness of reflexology as a symptomatic treatment for breast cancer12. Two non-randomised controlled clinical trials suggested favourable effects of reflexology for pain, but were at high risk of bias.

Four further studies not included in the reviews demonstrated reductions in pain but have considerable methodological limitations15,17,23,29. The first studied hospitalised patients undergoing chemotherapy and compared reflexology to standard care, finding no significant difference15. It was small (n=30) and lacked randomisation. The second studied patients with metastatic cancer hospitalized in an adult haematology ward (n=84) and compared reflexology to sole touching23. They found significant differences in pain, but there was very little information on the placebo intervention, sampling or inclusion criteria. The third was an RCT comparing the effectiveness of reflexology and aromatherapy for outpatients with cancer (n=115) but did not have an untreated control group29.  Within group comparisons revealed that both reflexology and massage were associated with statistically significant changes in pain. Another study (preference trial) in women with breast cancer (n=72) used allocation by preference to either reflexology or standard care and found less deterioration of pain, but was not randomised17.

A large (n=385) RCT of women with advanced stage breast cancer did not find any significant reduction in pain for reflexology compared to lay foot manipulation or standard care21

Quality of life, mental health

The 2011 systematic review by Ernst et al11  found that two 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.

In the 2010 breast cancer systematic review by Kim et al12 one large randomised controlled trial (RCT) showed a significant difference in quality of life and mood when compared with self-initiated support.

Four studies mentioned above (under Pain) also demonstrated reductions in anxiety/salivary cortisol, but conclusions are limited by their considerable methodological limitations15,17, 23,29. Another study of nursing home residents with cancer compared reflexology to Swedish massage (to lower extremities)22. It found both interventions were associated with significant changes to salivary cortisol levels, but no between group difference, and was a pilot study with a small (n=18) sample size.

An RCT of women with breast cancer receiving chemotherapy (n=60) compared reflexology to standard nursing care and used the EORTC QLQC30 Quality of Life Scale. They found significantly lower symptom total scores (p = 0.001) and significantly higher functional and general health scores (p = 0.000)24. However this study had a small sample size and unclear randomisation.

The large (n=385) RCT of women with advanced stage breast cancer mentioned above did not find any significant changes in anxiety or depression21

Self-reported concerns

The study mentioned above without an untreated control group also used Measure Yourself Concerns and Wellbeing (MYCaW) to explore the effect of reflexology on self-reported concerns. It found both interventions to be effective for patients’ self-reported problems/concerns29.  When post-treatment values were compared to the baseline values a slight advantage was indicated for reflexology.

Nausea and vomiting

In the 2010 systematic review by Kim et al of reflexology for breast cancer12, one non-randomised controlled clinical trial suggested favourable effects of reflexology for nausea but was at high risk of bias.

One trial evaluated the effect of reflexology compared to standard care on nausea and vomiting for women with breast cancer receiving chemotherapy (n=60)18. They found some reduction of index of nausea, vomiting and retching scores compared to control. However, the group allocation was by alternate day of attendance, sample size was small and baseline scores were higher in the reflexology group.

Chemotherapy-induced peripheral neuropathy

A pilot RCT (n=60) evaluated the effect of reflexology compared to standard care for the symptoms and functions of chemotherapy-induced peripheral neuropathy in various cancers16. No difference between groups apart from sensory function at the third time point were found. Attrition was high.

Healthcare service utilization and work-related productivity

An RCT evaluated the effect of reflexology compared to attention control on healthcare service utilization and work-related productivity in women with advanced breast cancer (n=256)25. They found evidence of fewer hospital visits in the reflexology group and some suggestion of improved absenteeism and presenteeism. This study was well conducted although follow-up was short.

Various outcomes

Wilkinson et al. (2008) carried out a systematic review based on 5 studies examining the effectiveness of reflexology for symptom relief in patients with cancer13. 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.

Four studies have since been published, evaluating reflexology for various symptoms.  The highest quality study is an RCT of 256 patient-carer dyads of breast cancer patients, which compared carer-delivered reflexology to attention control26. They found significant reductions in average symptom severity and interference, but not in various other social/relationship related outcomes. The positive effects seemed to reduce over time.  The preference trial in women with breast cancer mentioned above found improvements in fatigue and sleep17.  An RCT in adults with gynaecologic cancer (n=80) compared reflexology to progressive muscle relaxation (PMR), reflexology +PMR, or standard care27. Due to very poor reporting in this paper we cannot draw any conclusions from it. The final study was an RCT comparing reflexology, classical foot massage, and standard care for colorectal cancer patients receiving chemoradiotherapy (n=60)28. They found some improvements in various symptoms, but there was no follow-up and other methodological limitations.

The large (n=385) RCT of women with advanced stage breast cancer mentioned above found significant improvements in physical functioning for the reflexology group compared to the control group, including a reduction in the severity of dyspnoea21

An RCT (n=183) demonstrated that scalp massage (the active control group), but not reflexology induced a range of potentially beneficial immunological changes30.

Is it safe?

Adverse events

Some authors have reported adverse effects including fatigue and changes in kidney or bowel function1.

Contraindications

Anecdotal evidence suggests that the following may be contraindications: Gout, leg ulcers, peripheral vascular disease, deep-vein thromboses, infections, bruising, wounds and lymphoedema19.

Interactions

It has been purported that interaction with insulin is conceivable, dues to the possible stimulation of the pancreas during a treatment session1,2. 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 package20. Reflexologists do however state that they are not trained to diagnose diseases or to attempt to treat or cure specific medical conditions2.

References
  1. Ernst E, Pittler MH, Wider B and Boddy K. Oxford Handbook of Complementary Medicine. Oxford University Press (2008)..
  2. Pitman, V and MacKenzie, K. Reflexology: A practical approach (1997). Stanley Thornes.
  3. Association of Reflexologists UK website, accessed 27th March 2019.
  4. Kapila AKA, Herd A, Knife N, Chaplin P, Patel A. A Prospective Cohort Study on the Impact of Reflexology in Patients With Breast Cancer Using the MYCaW Scale. Clin Breast Cancer 2019; 2019;19:e319-e326
  5. Whatley J, Street R, Kay S. Experiences of breast cancer related lymphoedema and the use of reflexology for managing swelling: A qualitative study. Complement Ther Clin Pract 2018; 32: 123-129.
  6. 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.
  7. 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.
  8. Harris P, Finlay IG, Cook A, Thomas KJ, Hood K. Complementary and alternative medicine use by patients with cancer in Wales: a cross sectional survey. Compl Ther Med 2003; 11: 249-53.
  9. Molassiotis A et al. Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol 2005; 16: 655-3
  10. 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.
  11. Ernst E, Posadzki P, Lee MS. Reflexology: an update of a systematic review of randomised clinical trials. Maturitas 2011; 68(2):116-120.
  12. 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.
  13. Wilkinson S, Lockhart K, Gambles M, Storey L. Reflexology for symptom relief in patients with cancer. Cancer Nursing. 2008; 31 (5): 354-62. 
  14. 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.
  15. 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.
  16. Kurt S, Can G. Reflexology in the management of chemotherapy induced peripheral neuropathy: A pilot randomized controlled trial. Eur J Oncol Nurs 2018; 32: 12-19.
  17. Tarrasch R, Carmel-Neiderman NN, Ben-Ami S, Kaufman B, Pfeffer R, Ben-David M and  Gamus D. The Effect of Reflexology on the Pain-Insomnia-Fatigue Disturbance Cluster of Breast Cancer Patients During Adjuvant Radiation Therapy. J Altern Complement Med 2017; 24(1): 62-68.
  18. Ozdelikara A, Tan M. The Effect of Reflexology on Chemotherapy-induced Nausea, Vomiting, and Fatigue in Breast Cancer Patients. Asia Pac J Oncol Nurs 2017;  4(3): 241-249.
  19. Berenson SC. Management of cancer pain with complementary therapies. Oncology (Williston Park) 2007; 21(Suppl 4):10-22.
  20. 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.
  21. 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
  22. 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;456897.
  23. Jahani S, Salari F, Elahi N and Cheraghian B. The effect of reflexology in intensity of pain and anxiety among patients suffering from metastatic cancer in adults' hematology ward. Asian journal of pharmaceutical and clinical research 2018; 11(6): 401‐405.
  24. Ozdelikara A, Tan M. The effect of reflexology on the quality of life with breast cancer patients. Complement Ther Clin Pract 2017; 29: 122-129.
  25. Luo Z, Wang L, Sikorskii A, Wyatt G. Healthcare service utilization and work-related productivity in reflexology intervention for advanced breast cancer women. Support Care Cancer. 2018; doi: 10.1007/s00520-018-4592-4. [Epub ahead of print]
  26. Wyatt G, Sikorskii A, Tesnjak I et al. A Randomized Clinical Trial of Caregiver-Delivered Reflexology for Symptom Management During Breast Cancer Treatment. J Pain Symptom Manage 2017; 54(5): 670-679.
  27. Dikmen HA, Terzioglu F. Effects of Reflexology and Progressive Muscle Relaxation on Pain, Fatigue, and Quality of Life during Chemotherapy in Gynecologic Cancer Patients. Pain Manag Nurs 2019;20(1):47-53
  28. Uysal N, Kutluturkan S, Ugur I. Effects of foot massage applied in two different methods on symptom control in colorectal cancer patients: Randomised control trial. Int J Nurs Pract 2017; 23(3)
  29. Dyer J, Thomas K, Sandsund C, 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.
  30. Green VL, Alexandropoulou A, Walker MB et al. Alterations in the Th1/Th2 balance in breast cancer patients using reflexology and scalp massage. Exp Ther Med 2012. 1, 97-108
  31. Reflexology in Europe Website, Accessed 27th March 2019.

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