By Dónal P. O’Mathúna, PhD
Reflexology is an ancient therapy that is growing in popularity.1 In Denmark, for example, it is reported to be the most frequently used alternative therapy.2 In the United Kingdom, reflexology is thought to be the complementary therapy most frequently practiced by nurses.3 This popularity is likely to bring questions about its role and potential uses in clinical settings. To an observer, reflexology looks very much like a relaxing foot massage and is used most frequently to treat stress-related conditions such as backache, migraine, and allergies.3
However, reflexology is based on the view that specific regions called reflex zones (or reflex points) in the feet are connected to particular organs, glands, and regions of the body.4 The same principles are applied to reflexology of the hands and ears, but the focus of this review will be on reflexology of the feet.5 In addition to promoting a general relaxation response, reflexologists claim to be able to diagnose and relieve many conditions throughout the body. Understanding the foundations of reflexology, and the results of research exploring its utility, will help guide health care professionals responding to patients’ questions about reflexology.
Background
Ancient Chinese and Egyptian diagrams are believed to depict earlier forms of reflexology, although the modern approach was proposed in 1913 by William Fitzgerald, MD, a laryngologist at Boston City Hospital.6 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 ended 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.6 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.7
Mechanism of Action
Broadly speaking, three different mechanisms of action have been proposed for reflexology. One is that massaging of the reflex points stimulates specific nerves, thus improving blood flow around related organs and leading to healing or improved health in those organs.2 A second explanation 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.5 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 the nonphysical life energy (qi, for example) and meridian system that underlies other complementary therapies like acupuncture, shiatsu, and therapeutic touch.5 Reflexology employing this latter approach is therefore much more than a physical treatment, but also involves spiritual and emotional aspects.4
Regardless of how the reflex zones are believed to interconnect the body, all approaches to reflexology develop maps of the feet showing these connections (see Figure). 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)."4
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The practice of reflexology emphasizes the importance of the "evolving therapeutic relationship" between the patient and practitioner.8 Within this context, a variety of foot massaging techniques are used. Palpation of the feet is used to gather information on the patient’s overall health. Areas of the feet that are sensitive, painful, or gritty are noted.4 Changes in the skin are taken to indicate areas of energy stagnation in the corresponding zone. Denser areas suggest the need for deeper massage of those regions to decongest the energy. Several reflexology sessions will normally be suggested for maximum benefit.
Clinical Studies
Of central importance to reflexology are the zone maps of the feet. However, variations occur between these maps leading some to question the reliability and validity of these maps as diagnostic tools.8 One study examined the reliability of two reflexologists’ diagnostic skills.9 Both were blinded to the conditions present in 18 adults with between one and six previously specified medical conditions. Reflexologists were unable to accurately diagnose which patients had which conditions, and there was little agreement between the two therapists. The authors concluded that the results do not support the validity of reflexology as a diagnostic tool, but did acknowledge that the research design differed somewhat from the way reflexology normally is practiced.
Although many anecdotal reports claim successful outcomes after reflexology, very little controlled research has been carried out.3 A Danish study randomly assigned 30 subjects receiving steroids for their asthma to either conventional care or 10 weekly reflexology sessions (in addition to steroids).10 No significant differences were found between the two groups in symptoms measured or medication consumed.
Another randomized controlled study involved 83 women with 38 different premenstrual syndrome (PMS) complaints.11 Subjects monitored their own symptoms for two months and then were randomly assigned to either sham or true reflexology for eight weekly sessions. Reflex points on the subjects’ feet, hands, and ears were chosen on the basis of connections to parts of the body involved in PMS symptoms. Sham reflexology involved pressuring regions believed not to be associated with those parts of the body. Subject drop-out was a significant problem, with 33 withdrawing during the background phase and 15 more during the treatment phase. Among the 35 subjects completing the study, significantly greater reduction in PMS symptoms occurred in those who had received true reflexology (P < 0.01). Others have pointed out that the reflex points used in this study are classic acupuncture points, claiming this study supports the efficacy of acupressure, not reflexology.7
A pilot study with 18 patients given a number of reflexology treatments found statistically significant reductions in pre- and post-treatment heart rate and systolic blood pressure (P < 0.003).12 Diastolic blood pressure and respiratory rate were lower, but not with statistical significance. A control group was not used, and the authors acknowledged that the outcomes support a generalized relaxation response, not changes due to specific reflex points.
Another small study found some favorable results with 23 patients with either breast or lung cancer.13 In a cross-over design, subjects’ anxiety and pain levels were measured before and after 30 minutes of either reflexology or control, during which no intervention was given. Post-reflexology anxiety levels were significantly lower when compared both to pre-reflexology levels and to control (P = 0.000). Pain levels were significantly lower after reflexology compared to beforehand using three measurement tools (P < 0.005), and after the control intervention using one tool (P < 0.04). Only one of the three measurements found reflexology significantly more beneficial than control (P < 0.05).
In a Danish study, 220 patients with migraine or tension headaches received reflexology for up to six months.2 By the end of treatment, 78% reported their headaches relieved or cured, and three months later 81% reported continued relief or cure. A control group was not used, but it was noted that those taking migraine medication at the beginning of the study were less likely to report improvements during the study.
Adverse Effects
Serious adverse effects have not been reported after reflexology. A number of authors state that reflexology can elicit catharsis or a "healing crisis."14 This normally lasts only a couple of days. The symptoms can be physical, such as headache, nausea, diarrhea, or coldness, and emotional, such as periods of unexplained crying or depression. No controlled evidence is available to document the prevalence or cause of these symptoms, which usually are explained as resulting from the breakdown of crystalline products in the body as it detoxifies.5
Conclusion
Reflexology has very little scientific evidence to support its use. As it grows in popularity, some controlled evidence is becoming available. These studies do not appear to support the use of reflexology to diagnose medical illnesses, or to treat acute illnesses. A review of more than 8,000 cases in China found no evidence of effectiveness for acute conditions.6 However, cases in that review involving significant spiritual, psychological, environmental, dietary, or endocrine factors generally did display effectiveness. Some evidence, therefore, supports the use of reflexology as a means of inducing a general relaxation response.
Recommendation
Reflexology, like other forms of massage, may be an effective means of promoting relaxation, which in turn may be of benefit to patients with chronic, painful conditions. The limited form of massage involved in reflexology 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.12 Such findings lend support to the appropriate use of touch in health care settings, and the value of helping patients find procedures that promote relaxation. At the same time, patients should be encouraged not to rely on reflexology for diagnosis or treatment of serious medical conditions.
Dr. O’Mathúna is Professor of Bioethics and Chemistry at Mount Carmel College of Nursing, Columbus, OH.
References
1. Mackereth P, et al. Reflexology: Recent research approaches. Complement Ther Nurs Midwifery 2000; 6:66-71.
2. Launso L, et al. An exploratory study of reflexological treatment for headache. Altern Ther Health Med 1999; 5:57-65.
3. Lynn J. Using complementary therapies: Reflexology. Prof Nurse 1996;11:321-322.
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5. Griffiths P. Reflexology. Complement Ther Nurs Midwifery 1996;2:13-16.
6. Stephenson N, Dalton J. Using reflexology for pain management. A review. J Holist Nurs 2003;21: 179-191.
7. Botting D. Review of literature on the effectiveness of reflexology. Complement Ther Nurs Midwifery 1997; 3:123-130.
8. Mantle F, Mackereth P. Reflexology techniques are not an effective tool for symptom recognition or the diagnosis of medical conditions.’ Complement Ther Nurs Midwifery 2001;7:43-48.
9. White AR, et al. A blinded investigation into the accuracy of reflexology charts. Complement Ther Med 2000;8:166-172.
10. Petersen LN, et al. Ugeskrift For Laeger 1992;154:2065-2068. Cited in: Tiran D. The use of complementary therapies in midwifery practice: A focus on reflexology. Complement Ther Nurs Midwifery 1996;2:32-37.
11. Oleson T, Flocco W. Randomized controlled study of premenstrual symptoms treated with ear, hand, and foot reflexology. Obstet Gynecol 1993;82:906-911.
12. Dryden SL, et al. Just the ticket’: The findings of a pilot complementary therapy service (Part II). Complement Ther Nurs Midwifery 1999;5:15-18.
13. Stephenson NL, et al. The effects of foot reflexology on anxiety and pain in patients with breast and lung cancer. Oncology Nurs Forum 2000;27:67-72.
14. Mackereth P. An introduction to catharsis and the healing crisis in reflexology. Complement Ther Nurs Midwifery 1999;5:67-74.
O'Mathúna DP. Reflexology for Relaxation but not Diagnosis. Altern Med Alert 2003;6(8):90-93.
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