Reflexology for Pain and Anxiety in Cancer Patients
By Dónal P. O'Mathúna, PhD. Dr. O'Mathúna is Senior Lecturer in Ethics, Decision- Making & Evidence, School of Nursing, Dublin City University, Ireland; he reports no financial relationship to this field of study.
Reflexology is an ancient therapy that has become popular in some health care settings.1 Its use with cancer patients arises from its reputation for reducing pain, relieving anxiety, and promoting relaxation. The importance of addressing pain and anxiety, along with other psychosocial issues, is increasingly recognized in cancer services.2 Reflexology is one of a number of massage therapies available at major cancer centers in the United States and around the world.3 To a casual observer, reflexology can look very much like a relaxing foot massage. However, reflexology is based on a different theoretical foundation, leading to debate over whether reflexology offers additional benefits over foot massage.
Reflexology theory postulates that specific regions called reflex zones (or reflex points) in the feet and hands correspond to all organs, glands, and parts of the body.4 Application of thumb and finger pressure to the reflex zones is said to promote a balanced flow of energy to the associated regions of the body, which promotes circulation and eliminates toxins.1 With its growing popularity, clinicians may be asked by their patients who have cancer whether they are likely to experience any benefits from receiving reflexology.
Ancient Chinese and Egyptian diagrams are believed to depict early forms of reflexology. The modern approach was proposed in 1913 by William Fitzgerald, MD, a laryngologist at Boston City Hospital.5 Fitzgerald noticed that pressure applied to specific parts of the hands or feet induced anesthesia in other parts of the body. From this developed the idea of zone therapy, whereby the body is divided into 10 longitudinal zones. Controlled pressure applied to where a zone ends in the feet (a reflex zone) was theorized to elicit a response in the internal organs falling within that same zone. Beginning in the 1930s, Eunice Ingham, a massage therapist, further developed the therapy, reporting improvements in patients with illnesses as varied as asthma, angina, or arthritis.5 From these beginnings have developed several schools of reflexology that differ somewhat in the precise locations of various reflex zones and in the treatment methodology.6
Mechanism of Action
Broadly speaking, three different mechanisms of action have been proposed for reflexology. One is that massaging reflex points stimulates specific nerves, thus improving blood flow around related organs to restore homeostasis and promote relaxation.4 A second possible mechanism is that tension or illness in any organ will lead to the accumulation of tiny crystalline deposits of calcium and uric acid in the reflex zones of the feet.7 The pressure applied to the feet during reflexology then breaks up these deposits allowing them to be eliminated in a process called detoxification. The third proposed mechanism of action is based on manipulation of nonphysical life energy (qi, for example) and the associated meridian system that underlies other complementary therapies like acupuncture, shiatsu, and therapeutic touch.7
Regardless of how reflexology might influence distant parts of the body, all approaches work from maps of the feet and hands showing organ and regional connections. The maps are very specific, as exemplified by the following description. "On both feet, the spine runs along the medial aspects of the foot, the coccyx area is represented at the level of the heel, and the seventh cervical vertebra lies at the juncture of the great toe and foot. Many additional glands, organs, and body part reflex areas also are located in specific zones on the various areas of the feet (and hands)."8
Much of the early popularity with reflexology was based on anecdotal reports. Over the last decade, a small number of controlled studies examining reflexology for cancer patients have been published. These have involved relatively few participants, although an uncontrolled study with more than 1,000 cancer patients found that the patients, on average, reported a 50% decrease in pain and anxiety scores after massage.9 A variety of massage techniques were used, but almost half the participants received reflexology. Improvements were noted within one hour and persisted over the 48 hours of the study. However, a control group was not included.
A pilot study found some favorable results among 23 patients with either breast or lung cancer.10 In a cross-over design, subjects' anxiety and pain levels were measured before and after 30 minutes of either reflexology or a no-intervention control. Post-reflexology anxiety levels were significantly lower when compared both to pre-reflexology levels and to control (P = 0.000). Pain levels were also reportedly lower for the breast cancer patients (n = 13), though significant differences between reflexology and control were found with only one of the three pain measurement instruments used.
In another pilot study led by the same researcher, 26 inpatients with metastatic cancer were randomly assigned to receive reflexology twice, with a 24-hour interval in between sessions, or no intervention.11 Pain scores were significantly lowered immediately after reflexology compared to the control (P < 0.01), but no differences existed three and 24 hours after intervention.
Thirty cancer patients, upon hospitalization, were randomly assigned to receive reflexology or no intervention.12 State-anxiety was measured before, immediately after, and 24 hours after intervention. Anxiety was reduced after reflexology, with the average score being significantly lower than in the control group (P < 0.05). One day later, the score in the reflexology group had not changed significantly from the immediate post-treatment measurement.
Reflexology was taught to 42 partners of patients with metastatic cancer and compared with a control intervention where another 44 partners read to patients with similar diagnoses.4 The intervention was assigned randomly to the participant couples. Each intervention lasted 30 minutes, before and after which pain and anxiety were assessed with validated instruments. On average, anxiety decreased by 62% in the reflexology group compared to 23% in the control group (P = 0.001). Pain decreased by 34% after reflexology compared to 2% in the control (P = 0.001).
Some studies have compared reflexology with foot massage. One study randomly assigned 12 cancer patients receiving only palliative care to reflexology or foot massage.13 The same reflexologist administered the assigned intervention to each participant on days 1, 3, and 5. All participants had improved quality-of-life scores on a visual analogue scale, with the reflexology group improving significantly more (P = 0.004).
In a pilot study, 17 patients with advanced cancer were randomly assigned to receive either reflexology or foot massage weekly for 6 weeks.14 On average, the scores for anxiety and depression did not change over the course of the study, nor did they vary between the two groups. A number of other mood levels and symptoms were measured, with no statistical differences between the two groups.
The largest controlled trial to date involving cancer patients is an unpublished study reported in a systematic review.15 The 129 participants were randomly assigned to weekly reflexology, foot massage, or no intervention during the first four weeks of radiotherapy. Using measures of mood and fatigue, the reflexology group had significantly better scores than the foot massage group (P = 0.006). The latter also scored significantly better than the no intervention group.
Serious adverse effects have not been reported after reflexology. However, only one of the controlled trials explicitly reported whether adverse effects occurred with reflexology.14 Of the seven participants receiving reflexology, six reported foot discomfort as an adverse effect; among the 10 receiving foot massage, two reported foot discomfort. Two from each group also reported nausea, shaking, or sleep disturbance that they attributed to therapy. Some authors warn that reflexology can elicit a "healing crisis" with symptoms such as headache, nausea, diarrhea, or emotional reactions such as periods of unexplained crying.16 No controlled evidence is available to document the prevalence or cause of these symptoms, which reportedly can even last for a couple of days.7
Some reflexologists claim to be able to diagnose illnesses using feet zone maps. However, these maps differ from one authority to another.17 An empirical study of two reflexologists' ability to diagnose medical conditions using such maps found them inaccurate with little agreement between the two therapists.18
Some controlled evidence is available to support the use of reflexology for the relief of pain and anxiety in cancer patients. However, the total number of studies is relatively small and the results are not unambiguous. Many of the studies had few participants and some methodological weaknesses. There is insufficient evidence to determine whether the benefits, if any, arise from the general massaging aspects of reflexology or are specific to the reflexology technique, or might simply be related to the healing potential of human touch.
Reflexology, like other forms of massage, may be an effective means of promoting relaxation, which may help to reduce pain and anxiety in cancer patients. The way reflexology is limited to specific parts of the body may be attractive to some, such as where women in one study preferred reflexology of the feet rather than hands, whereas men had no preference.19 Such findings lend support to the appropriate use of touch in health care settings, and the value of helping cancer patients find procedures that promote relaxation.3 Reflexology can be considered an appropriate adjunct in the treatment of pain and anxiety for people with cancer provided skilled, experienced providers are available. At the same time, however, patients should be encouraged not to rely on reflexology alone for diagnosis or treatment of serious medical conditions.
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