Description
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.
Efficacy
Evidence is available from three systematic reviews including twenty individual trials in cancer patients, and twelve additional randomised controlled trials.
Fatigue: A SR and two RCTs found that reflexology may improve fatigue in breast cancer, but evidence is not of a high enough level to be conclusive. RCTs in other cancer populations found mixed and inconsistent results regarding fatigue.
Pain: A SR and four RCTs indicate improvements in pain, but all the findings are limited by methodological shortcomings of the controlled clinical trials.
Mental health: A SR was unable to make recommendations regarding reflexology for anxiety in cancer, and three of the six controlled clinical trials report no improvements, and all studies have methodological limitations.
QoL: One SR and an RCT indicate reflexology may improve QoL, but the studies included in the review have low certainty of evidence, and the review itself has some limitations.
Nausea and vomiting: One RCT indicates a reduction in antiemetic medication, but findings are limited by a lack of nausea in the patient group.
Chemotherapy-induced peripheral neuropathy: One RCT indicates improvement in symptoms.
Other: One large good-quality RCT reports positive results for healthcare utilization and work-related productivity, including symptom severity and interference in cancer patients receiving reflexology.
Safety
Reflexology generally has a good safety record.
Citation
Lorenc A, CAM Cancer Collaboration. Reflexology [online document], Nov 8, 2023
Document history
Fully revised and updated in October 2023 and March 2019 by Ava Lorenc. Updated in October 2016, September 2014 and June 2012 by Helen Cooke. Summary first published in March 2011, authored by Helen Cooke. Next update due: October 2026.
Description
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 (Ernst 2008).
Background and prevalence
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 (Pitman 1997). No recent prevalence data are available.
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. (Ernst 2008) 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 (AoR 2023). 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 sweats (Kapila 2019) and a reconnection with their ‘self’ (Whatley 2018).
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.
Mechanisms of action
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 Tsay 2008);
- rebalancing hormones similarly to mindfulness and exercise (Whatley 2022);
- kinetic chains transmitting force through the myofascia, which may also affect proprioception (Whatley 2022);
- 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 (Tsay 2008);
- 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 (Stephenson 2000);
- a relaxing effect which contributes to relieving tension and stress affecting the autonomic response, which, in turn, affects the endocrine, immune, and neuropeptide systems (Whatley 2022);
- mechanical force converting into biochemical changes via mechanotransduction, which produces cellular responses from mechanosensitive cells including physical and chemical communication processes (Chaitow 2018).
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 Network.
Supportive care
Three systematic reviews (SRs) including 20 individual trials on reflexology and cancer were assessed for this summary (Lee 2015; Tian 2023; Wanchai 2020). For details of the SRs please see table 1. All studies included in the reviews had significant methodological limitations. The systematic reviews varied in quality, all searched adequate sources and used independent article selection and data extraction. Lee (2015) conducted an excellent meta-analysis and Tian (2023) conducted meta-analysis where data were homogenous enough, but Wanchai (2020) did not consider meta-analysis. Two other SRs were not used, as they are now out of date and all included studies were either included in more recent SRs, unpublished, or were not RCTs (Ernst 2011; Wilkinson 2008).
The most recent SR included studies of mental health outcomes in any type of cancer (Tian et al 2023) and found 15 RCTs of 1356 participants. The authors only included English-language studies and did not assess publication bias. Meta-analysis was only possible for one outcome, anxiety. The potential impact of risk of bias in individual studies on the results of the meta-analysis was not assessed.
Wanchai (2020) included studies of reflexology for breast cancer and found 6 studies (4 RCTs, 2 quasi-experimental). Their searches were adequate but could have included more databases, the review was not registered, and they did not consider meta-analysis nor synthesise quality assessment results.
Lee (2015) 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.
Twelve additional studies have been published since/were not included in the above reviews (Dyer 2013; Gholamzadeh 2023; Hesami 2019; Luo 2019; Mazloum 2023; Murat-Ringot 2021; Nourmohammadi 2019; Quattrin 2006; Rambod 2019; Rezaei 2022; Tarrasch 2017; Wyatt 2021). Two of these studies were non-randomised trials (Quattrin 2006; Tarrasch 2017) while the rest for randomized controlled trials (RCTs). For details of all trials please see table 2.
Fatigue and sleep
The systematic review by Wanchai (2020) investigated the effects of reflexology on symptoms and side effects of breast cancer. They included two studies measuring fatigue (n=445) which found that reflexology significantly reduced fatigue; however their overall conclusion was that not enough high-level evidence has been reported to confirm the effectiveness of reflexology on breast cancer symptom management.
Six studies not included in Wanchai (2020) also measured the effects of reflexology on fatigue (Hesami 2019; Mazloum 2023; Nourmohammadi 2019; Rambod 2019; Tarrash 2017; Wyatt 2021). Two included women with breast cancer. The first was an RCT which compared reflexology to no intervention for women with breast cancer (n=57) and found a significant difference in fatigue severity between the experimental (20.66±4.54) and control (40.36±9.58) groups (p=0.000) as measured by the fatigue severity scale (FSS). (Nourmohammadi 2019) However, the study is poorly reported, unregistered, used an inappropriate randomisation method and had a higher dropout rate in the intervention group. The second was a preference trial in women with breast cancer (n=72) using allocation by preference to either reflexology or standard care and found significant lower levels of fatigue in intervention compared to control group after 5 weeks of radiation therapy (p < 0.001), but was not randomised (Tarrasch 2017).
A third study was an RCT of cancer patients undergoing chemotherapy (n=80) and found a significant difference between reflexology and no intervention in terms of fatigue (p = 0.016) (Hesami 2019). This study is fairly well conducted with no loss to follow up and fidelity monitoring. A fourth study was an RCT of cancer patients undergoing radiotherapy who have fatigue (n=62) (Mazloum 2023). They compared reflexology to a warm footbath and found significant reductions in all dimensions of the Multidimensional Fatigue Inventory scores in the reflexology group compared to the footbath group at 28 days (p < .05), except for the score of the Reduced Activity Dimension on day 7. This study reported only minimal information on randomisation procedure so has a risk of bias.
The fifth study was an RCT of lymphoma patients (n=72) comparing reflexology to no intervention (Rambod 2019). They found significant difference between the two groups regarding fatigue and sleep quality (p < 0.05). The study is well reported although the cited trial registration could not be found. The final study is a Sequential Multiple Assignment Randomized Trial comparing reflexology (caregiver-provided), reflexology followed by meditative practices, meditative practices or meditative practices followed by reflexology for patients with cancer and their caregivers (n=347 dyads) (Wyatt 2021). They found no differences between reflexology and meditative practices groups created by the first randomization. The unusual design is usually used for interventions with proven efficacy and the study had high attrition rates.
Pain
The systematic review by Lee et al investigated the effects of massage therapy on pain in any type of cancer (Lee 2015). 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.
Four further studies not included in the reviews demonstrated reductions in pain but have considerable methodological limitations. The first studied hospitalised patients undergoing chemotherapy and compared reflexology to standard care, finding no significant difference (Quattrin 2006). It was small (n=30) and lacked randomisation.
The second was an RCT comparing the effectiveness of reflexology and aromatherapy for outpatients with cancer (n=115) but did not have an untreated control group (Dyer 2013). Within group comparisons revealed that both reflexology and massage were associated with statistically significant changes in pain. Dyer (2013) also used Measure Yourself Concerns and Wellbeing (MYCaW), showing both interventions to be effective for patients’ self-reported problems/concerns. (Dyer 2013) and a slight advantage for reflexology when post-treatment values were compared to the baseline values.
A third study comparing reflexology to standard care for lymphoma patients found significant improvement in pain and was fairly well reported. (Rambod 2019) The preferential RCT by Tarrasch (2017) mentioned above under fatigue found no significant pre-post differences in pain in the reflexology group while pain increased at some time points in the control group.
Mental health
The systematic review by Tian et al investigated the effects of (foot, hand or ear) reflexology on mental health (anxiety, stress, depression, QoL) in adults with cancer (Tian 2023). They included 15 RCTs on 1356 participants, most of which had a high risk of bias. Meta-analysis was only possible for one outcome due to heterogeneity. They concluded that reflexology is more likely to have an effect on QoL than anxiety or depression but low to very low GRADE certainty of evidence means an unequivocal recommendation supporting reflexology could not be made.
An RCT of reflexology compared to usual care for women with breast cancer (n=66) found no difference in anxiety between groups (Rezaei 2022), although the sample was small, and the intervention appears to only be for one day. Another RCT of reflexology compared to usual care for digestive or lung cancer patients (n=80) found no difference for QoL or anxiety, although there was high loss to follow up, partly due to adverse events (although these weren’t caused by the intervention (Murat-Ringot 2021). Wyatt 2021 (described above under Fatigue) also found no difference between reflexology and meditative practices for depression and anxiety.
Three studies mentioned above (under Pain) also demonstrated reductions in anxiety/salivary cortisol, but conclusions are limited by their considerable methodological limitations. (Quattrin 2006; Tarrasch 2017; Dyer 2013).
Quality of life
The SR by Tian 2023 (see above Mental health) concluded that reflexology is more likely to have an effect on QoL than anxiety or depression but low to very low GRADE certainty of evidence means an unequivocal recommendation supporting reflexology could not be made.
An additional RCT of reflexology compared to usual care for colorectal cancer patients with chemotherapy-induced peripheral neuropathy (CIPN) (n=80) found a significant improvement in QoL in the reflexology group (Gholamzadeh 2023), although some key information is not reported in this paper.
The Sequential Multiple Assignment Randomized Trial mentioned above with patient-carer dyads found no differences in the M.D. Anderson Symptom Inventory (MDASI) Summed Symptom Severity Index (Wyatt 2021)
Nausea and vomiting
The RCT mentioned above (under Mental health) for digestive or lung cancer patients had chemotherapy induced nausea and vomiting as its primary outcome (Murat-Ringot 2021). They found significantly less frequent consumption of antiemetic drugs in the reflexology group compared to usual care (p=0.04), although the levels of nausea in the sample were low to start with.
Chemotherapy-induced peripheral neuropathy (CIPN)
The RCT mentioned above (under Mental Health) for colorectal patients with CIPN found that reflexology was associated with positive effects in terms of improvement of CIPN: sensory (p=0.01), motor (p=0.031), and autonomic symptoms (p=0.034) (Gholamzadeh 2023).
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) (Luo 2018). 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.
Reflexology generally has a good safety record, although data on safety is limited.
Adverse events
Two SRs reported adverse effects. Tian (2023) found four studies reported no adverse effects, but one study mentioned less common to rare adverse effects, including foot discomfort, nausea, shaking, or sleep disturbance, possibly linked to reflexology. Wanchai (2020) found no adverse effects reported; however, only one of the included trials appears to have collected information on adverse effects.
Among the additional studies included in this summary, two reported on adverse effects. The RCT with lymphoma patients found no adverse effects (Rambod 2019). In the study of digestive and lung cancer patients, adverse events were experienced by 12 participants, 7 of whom were in the reflexology group, but none of the adverse events were attributed to foot reflexology, according to the physicians. (Murat-Ringot 2021) Some authors have reported adverse effects including fatigue and changes in kidney or bowel function. (Ernst 2008).
Contraindications
Anecdotal evidence suggests that the following may be contraindications: Gout, leg ulcers, peripheral vascular disease, deep-vein thromboses, infections, bruising, wounds and lymphoedema. (Berenson 2007)
Interactions
It has been purported that interaction with insulin is conceivable, due to the possible stimulation of the pancreas during a treatment session. (Ernst 2008; Pitman 1997) 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. (White 2000). Reflexologists do, however, state that they are not trained to diagnose diseases or to attempt to treat or cure specific medical conditions. (Pitman 1997)
Association of Reflexologists UK website, accessed 24th October 2023.
Berenson SC. Management of cancer pain with complementary therapies. Oncology (Williston Park) 2007; 21(Suppl 4):10-22.
Chaitow L. Fascial well-being: Mechanotransduction in manual and movement therapies. J Bodyw Mov Ther. 2018 22(2):235-236
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.
Ernst E, Pittler MH, Wider B and Boddy K. Oxford Handbook of Complementary Medicine. Oxford University Press (2008).
Ernst E, Posadzki P, Lee MS. Reflexology: an update of a systematic review of randomised clinical trials. Maturitas 2011; 68(2):116-120.
Gholamzadeh, H., M. Ilkhani, B. Abedini, A. Ameri, N. Shakeri, and A. Mohammadabadi. 2023. 'The Effect of Reflexology on Quality of Life in Colorectal Cancer Patients Suffering Chemotherapy-induced Neuropathy: a Randomized and Controlled Trial', Turk onkoloji dergisi, 38: 228‐37.
Hesami, M., M. Kalhor, D. Roshani, and M. Fathi. 2019. 'The effect of reflexology on fatigue in cancer patients receiving chemotherapy: a randomized controlled trial', Crescent journal of medical and biological sciences, 6: 151‐57.
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
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.
Luo, Z., et al. (2019). "Healthcare service utilization and work-related productivity in reflexology intervention for advanced breast cancer women." Supportive care in cancer 27(8): 2837‐2847
Mazloum, S. R., M. Rajabzadeh, S. Mohajer, H. Bahrami-Taghanaki, and M. Namazinia. 2023. 'Comparing the Effects of Warm Footbath and Foot Reflexology on the Fatigue of Patients Undergoing Radiotherapy: a Randomized Clinical Trial', Integrative cancer therapies, 22: 15347354231172940.
Murat-Ringot, A., P. J. Souquet, F. Subtil, F. Boutitie, M. Preau, and V. Piriou. 2021. 'The effect of foot reflexology on chemotherapy-induced nausea and vomiting in patients with digestive or lung cancer: randomized controlled trial', JMIR cancer, 7: e25648.
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.
Nourmohammadi, H., M. Motaghi, M. Borji, A. Tarjoman, and B. Soltany. 2019. 'The Effects of Reflexology on Fatigue Severity of Patients with Cancer', Asian Pacific journal of cancer prevention, 20: 391‐94.
Pitman, V and MacKenzie, K. Reflexology: A practical approach (1997). Stanley Thornes.
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.
Rambod, M., N. Pasyar, and M. Shamsadini. 2019. 'The effect of foot reflexology on fatigue, pain, and sleep quality in lymphoma patients: a clinical trial', European journal of oncology nursing, 43: 101678.
Reflexology in Europe Website, Accessed 24e October 2023.
Rezaei, M., V. Naseri-Salahshour, F. Rafiei, F. Mohagheghi, and M. Sajadi. 2022. 'Effect of Foot Reflexology on Anxiety in Women with Breast Cancer: a Randomized-controlled Trial', Journal of evidence-based care, 11: 33‐39.
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.
Tarrasch R, Carmel-Neiderman NN, Ben-Ami et al. 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.
Tian, E. J., Y. Veziari, M. J. Leach, and S. Kumar. 2023. 'The effectiveness of reflexology on mental health in cancer patients: A systematic review and meta-analysis of randomised controlled trials', Complement Ther Clin Pract, 50: 101708.
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.
Wanchai A, Armer JM. A systematic review association of reflexology in managing symptoms and side effects of breast cancer treatment. Comp Ther Clin Pract 2020. 38: 101074e
Whatley J, Perkins J, Samuel C. ‘Reflexology: Exploring the mechanism of action’ Comp Ther Clin Pract 2022. 48: 101606
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.
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.
Wilkinson S, Lockhart K, Gambles M, Storey L. Reflexology for symptom relief in patients with cancer. Cancer Nursing. 2008; 31 (5): 354-62.
Wyatt GR, Lehto P, Guha-Niyogi S, et al. 2021. Reflexology and meditative practices for symptom management among people with cancer: results from a sequential multiple assignment randomized trial', Research in nursing & health, 2021;44: 796‐810.
