Sackler School of Medicine, Tel Aviv University, Tel Aviv
In the modern age of healthcare, many individuals have chosen to take a consumer approach in selecting the type of care they are interested in receiving. With the rise in popularity of Complementary Alternative Medicines (CAM), consumers of healthcare are interested in a wide range of modes of care for their ailments. In fact, a recent study reported that “more than 80% of women with breast cancer turn to complementary and integrative health (CIH) therapies for symptom management” (Wyatt, 2017). Mainstream CAM usage has prompted the scientific community to define what CAM is, and to understand the plethora of modalities offered. The term CAM is a broad description that encompasses “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine” (NCCIH). CAM is typically divided into five general categories: Mind & Body medicine, Biological-based Practices, Manipulative & Body-based Practices, Energy Medicine, and Whole Medical Systems. This literature review will focus on the therapeutic use of reflexology, a manipulative & body-based practice. This modality will be evaluated through recent studies that assessed claims of “significant beneficial outcomes” as well as the proficiency required to deliver care to patients (Hart, 2015).
The practice of reflexology is defined as “a non-invasive complementary practice involving the use of alternating pressure applied to reflexes within reflex maps of the body, located on the feet, hands, and outer ears” (RAA). The popularity of reflexology has grown so much that it is now one of the top six CAM treatments used in the United Kingdom (Hart, 2015). It is not uncommon to hear endorsements like, “reflexology is a powerful adjunct therapy that can be extremely beneficial” and experts promoting that “It is important to attend a fully qualified reflexologist preferably, what may be referred to as a clinical reflexologist” (Hart, 2015). Yet while individuals like Lisa Mueller, director of the Reflexology Association of America (RAA), claims that “there have been significant beneficial outcomes for patients as a result of incorporating reflexology” (Hart, 2015), the literature has not demonstrated many direct gains by the utilization of reflexology as adjunct care nor of proof demonstrating the need for a “clinical reflexologist” to attain these aims.
A sleep laboratory study from Belgium sought to explore the effects reflexology on sleep architecture for patients suffering from sleep disorders (Véron, 2012). The study involved spending three nights at the sleep lab, where each patient served as their own control and each received one twenty-minute session during either night two or three of their stay. A polygraph was used to measure changes in sleep architecture overnight, and perceived outcomes were entered into a Visual Analogue Scale (VAS), which is a measurement instrument for subjective characteristics or attitudes that cannot be directly measured. While the polygraph measuring sleep architecture indicated there were no statistically significant differences between nights with and without reflexology, the VAS for sleep quality showed a statically significant increase (Véron). Patients reported that the reflexology session improved sleep quality, despite no measured changes in brain waves. To the authors of the study, this suggested that “[reflexology] stimulates endogenous factors causing a feeling of well-being and comfort in those patients” (Véron, 2012). Therefore, unsurprisingly, patients reported that a service tantamount to a foot massage before sleep aided in relaxation. The question remains, is this gain unique to the application of skill by a professional reflexology practitioner, or can anyone provide this service?
A recent study explored the use of home-based reflexology delivered by a friend/family caregiver for symptom management during breast cancer treatment (Wyatt, 2017). In this study, a control group was compared to the reflexology care group in which a caregiver received two home visit training sessions by a trained reflexologist. The first visit was utilized to demonstrate the 30-minute session, and during the second visit the caregiver was required to exhibit the ability to perform the protocol with 90% accuracy. From that point, the caregiver was left with illustrations and contact information in case they needed support. Patients then used the “M. D. Anderson Symptom Inventory (MDASI)” for self-report on the severity of a myriad of symptoms including pain, fatigue, nausea, and others. While the study did show some statically significant difference in reports of fatigue and pain between the two groups, an additional parameter emerged as an inseparable aspect of the study. These practitioners were not skilled and seasoned experts applying their skills to ameliorate symptoms, but rather laymen with very minimal training. Therefore, it is not clear whether it is the expertise of the practitioner that really matters or merely the contact and relationship with the individual applying the modality.
A recent study was conducted to examine the possibility of “delivering reflexology to people moderately to severely affected by multiple sclerosis and to investigate the effect on a range of symptoms” (Miller, 2012). Of note in this study is the approach to measure the effects of reflexology when compared against a placebo response. The groups were divided into a reflexology group and a sham reflexology group that utilized services from the same practitioner but were only provided with a non-therapeutic foot massage. This study found no statistically significant difference between the groups receiving reflexology and sham-reflexology and stated that, “results do not support the use of reflexology for symptom relief in a more disabled multiple sclerosis population and are strongly suggestive of a placebo response” (Miller, 2012). Further, the improvements noted in the study were small and insignificant, leading the authors to posit that “reflex points used in reflexology are perhaps not as specific a location as previously suggested” (Miller, 2012). The authors eventually concluded that the therapist relationship with the participants may have had more of an influence on the results than the treatment.
The Miller study revealed several salient points that have been demonstrated in previous literature as well. First, perhaps the proficiency in locating and utilizing pressure points for the practice of reflexology has been overstated. The Wyatt study showed that a layman with minimal training and expertise was able to deliver what they claimed to be gains on par with that of a trained reflexologist. Next, the very nature of the modality is suspect. Human contact in the appropriate context is known to alleviate anxiety and stress, and evidence of this dynamic was discussed in all three studies. However, there is still a major difference between stating that human contract can bring about positive gains and claiming that the use of reflexology is the specific modality that delivered these benefits.
In the ever-changing sphere of healthcare trends, one fact is certain: CAMs have become an inseparable part of what patients view as worthwhile supportive care. As future physicians we must decide whether a modality that often performs no better than placebo is a treatment option we want to endorse to our patients. Our first duty is to “Do No Harm”, but as Miller so aptly stated, “Treatment was well tolerated… no adverse effects being noted”. Therefore, is a modality which “does no harm” good enough considering its secondary gains, or do we as clinicians strive to attain something more for our patients? That is a question we need to answer for ourselves.
Hart, J. (2015). Reflexology: Emerging Evidence Points to Health Benefits. Alternative and Complementary Therapies, 21(3), 121–123. https://doi.org/10.1089/act.2015.29000.jh
Miller, L., McIntee, E., & Mattison, P. (2013). Evaluation of the effects of reflexology on quality of life and symptomatic relief in multiple sclerosis patients with moderate to severe disability; A pilot study. Clinical Rehabilitation, 27(7), 591–598. https://doi.org/10.1177/0269215512469383
National Center for Complementary and Integrative Health. The Use of Complementary and Alternative Medicine in the United States. Online document at: https://nccih.nih.gov/research/statistics/2007/camsurvey_fs1.htm
Reflexology Association of America. Definition of Reflexology. Online document at: http://reflexology-usa.org/information/raas-definition-of-reflexology/
Véron, R., Balestra, C., Berlémont, C., Lanquart, J.-P., & Jurysta, F. (2012). P-1359 – The impact of foot reflexology on sleep induction in patients suffering from sleeping disorders. European Psychiatry, 27, 1. https://doi.org/10.1016/S0924-9338(12)75526-8
Wyatt, G., Sikorskii, A., Tesnjak, I., Frambes, D., Holmstrom, A., Luo, Z., … Tamkus, D. (2017). A Randomized Clinical Trial of Caregiver-Delivered Reflexology for Symptom Management During Breast Cancer Treatment. Journal of Pain and Symptom Management, 54(5), 670–679. https://doi.org/10.1016/j.jpainsymman.2017.07.037