All About Reflexology Part 1 of the Reflexology Presentations.
Clients' perceptions of the benefits of reflexology on their quality of life
Transcript of Clients' perceptions of the benefits of reflexology on their quality of life
Correspondence to:Dr. ShelaghWright,Research Fellow,ARC Cancer SupportCentre, 65, Eccles Street,Dublin 7, Ireland.Tel.: 018307333;Fax: 018307595.
S.Wright, Ph.D., BA(Hons), RGN, RM.ResearchFellow, ARC CancerSupport Centre, Dublin,Ireland.
U.Courtney, M.Med.Sc.,RGN, Director, ARCCancer Support Centre,Dublin, Ireland.
C.Donnelly, BN., ITEC.Dip. Re£exology &Aromatherapy.Cert.Ed.
T.Kenny, ITEC. Dip.Re£exology, Aromatherapy& Massage.Cert.Ed.
C.Lavin, ITEC. Dip.Re£exology, Aromatherapy,Massage & Nutrition.
Clients’perceptions of thebenefits of re£exology ontheir quality of lifeS. Wright,U.Courtney,C.Donnelly,T. Kenny and C.Lavin
Awareness has increased among health-care professionals, patients and the general publicof the importance of an holistic approach to cancer care. Psychosocial interventions,including complementary therapies, mayhelp to improve the qualityof life (QoL) ofpeoplewithcancerbyhelping toreduce the distress associatedwiththe diagnosis andtreatmentofcancer and by facilitating improved psychological adjustment to the experience of cancer.The following article presents anecdotal f|ndings at ARC Cancer Support Centre Dublin,Ireland, of clients’perceptions of the benef|ts of reflexology interventions on their QoL.Reflexology interventions were perceived to impact positively upon clients’ levels ofimpairment and functional status, including physical and psychological function, withimplications for general health perceptions.The paper discusses how these f|ndings mightformthe basis of further, more rigourous evaluation of the benef|ts of reflexology forpeoplewith cancer at ARCCancer Support Centre.r 2002 Elsevier Science Ltd. Allrightsreserved.
The author, director and re£exologists enjoying Christmas 2001 at ARC Cancer Support Centre, Dublin; from left to right:Cora Lavin, Shelagh Wright,Carol Donnelly,Terry Kenny and Ursula Courtney.
INTRODUCTION
While QoL factors have heightened awareness
among patients, the general public and health-
care professionals of the relevance of an holistic
ComplementaryTherapies in Nursing &Midwifery (2002) 8, 69^76 # 2002 Elsevier Sciendoi:10.1054/ctnm.2001.0593, available online at http://www.idealibrary.com on
approach to cancer care, it is also recognized that
complementary therapies require evaluation to
ascertain the impact they have on the QoL of
patients with cancer (Fallowfield 1995, Bell &
Sikora 1996, Richardson 2000, Gambles et al.
ce Ltd. All rights reserved.
70 ComplementaryTherapies in Nursing &Midwifery
2001). ARC (Aftercare, Research, Counselling)
Cancer Support Centre is a non-profit-making
registered charity situated in Dublin, Ireland,
which offers a range of psychosocial interven-
tions, including complementary therapies, edu-
cative and behavioural therapy, counselling and
group support for people with cancer as well as
their partners and/or carers. The present article
offers an overview of initial, anecdotal findings at
ARC Cancer Support Centre related to clients’
perceptions of the benefits of reflexology upon
their QoL.
LITERATURE REVIEW
Complementary therapy as apsychosocial intervention to improveQoL
There is an increased awareness of the necessity
for early intervention to pre-empt and alleviate
both the trauma of a diagnosis of cancer and the
adverse physical and psychological symptoms
associated with the illness experience and treat-
ment of cancer (Cella et al. 1990, Mermelstein &
Lesko 1992, Munkres et al. 1992, Spiegel 1993,
Burish & Redd 1994, Cordova et al. 1995, Ferrell
1995, Tjemsland et al. 1996, Holland 1999).
Psychosocial interventions, including comple-
mentary therapies, such as light massage, aro-
matherapy, relaxation and reflexology, provided
in association with conventional cancer treat-
ment, may help to reduce the experience of
anxiety and distress for people with cancer, by
promoting the relaxation response, providing
emotional support and enhancing emotional
control, mood and psychological well-being
(Benson 1976, Fallowfield 1995, Greer et al.
1992, Doan 1998, Penson 1998, Laffoy 1999,
Hodgson 2000, Stephenson et al. 2000). Com-
plementary therapies may fulfil an important
psychological need for some patients with cancer
(Downer et al. 1994). These interventions offer
support and acceptance to patients, and may
help them to acknowledge and cope with feelings
of uncertainty, anxiety, anger, loss and grief
associated with the cancer experience, while
assisting with symptom reduction (Crowther
1991, Ferrell-Torry & Glick 1993, Downer et
al. 1994, Sloman 1995, Bell & Sikora 1996,
Trousdale 1996, Penson 1998, Hodgson 2000,
Stephenson et al. 2000). Psychosocial support
has been shown to have an important influence
on improved psychological adjustment to the
illness of cancer (Watson 1983, Dunkel-Schetter
1984, Dunkel-Schetter et al. 1992, Spiegel 1993,
Arathuzik 1991a, 1991b, 1994). Complementary
therapies offer the possibility of more choice and
control for people who are faced with life-
threatening illness (Penson 1998) and may
improve the element of care received, with major
implications for sense of well-being and QoL
(Benner & Wruble 1989).
RATIONALEFOR REFLEXOLOGYASATHERAPEUTICINTERVENTION
The theory of re£exology
Reflexology is a form of foot and hand pressure
therapy designed to improve nerve communica-
tion, harmonize physiological function and
promote the relaxation response (Crane 1997,
Kuhn 1999, Stephenson et al. 2000). There are
several theories related to the effects of
reflexology, one being the theory of proprio-
ceptive nervous receptors, emphasizing the
interconnections throughout the central and
peripheral nervous systems (Stephenson et al.
2000). The reflex arc is a relatively simple
nervous circuit without conscious control being
involved (Crane 1997). The practice of reflexol-
ogy is based on the premise that there are reflex
points on the hands and feet which correspond to
all muscles, nerves, organs, glands and bones in
the body (Crane 1997, Kuhn 1999, Hodgson
2000), and involves the application of gentle
pressure to the hands and/or feet to stimulate
these reflex points (Crane 1997, Hodgson 2000).
Nerve impulses can become blocked when illness
brings about an imbalance in function. Pressure
on specific points on the hands and feet is
considered to promote better blood flow and
nerve impulses, release of toxins and endorphins,
facilitating enhanced function and sense of well-
being (Kuhn 1999). The use of reflexology
promotes the induction of the relaxation re-
sponse and thus may have an effect on anxiety
reduction (Crane 1997, Stephenson et al. 2000).
AIMOF STUDY
The study retrospectively examined clients’ per-
ceived benefits of reflexology interventions, to:
K Identify clients’ perceptions of the benefits
of reflexology interventions upon their QoL.
K Identify whether there were common
themes related to clients’ perceived benefits
of reflexology interventions.
K Determine the perceived impact of
reflexology interventions upon different
domains of QoL.
METHODOLOGY
Reflexology charts were kept by therapists from
the commencement of interventions at ARC
Clients’ perceptions of the benefits of re£exology 71
Cancer Support Centre in 1998. All clients
received medical consent before undergoing
reflexology treatments at weekly intervals. Cli-
ents’ qualitative, evaluative comments were
recorded on an ongoing basis during the course
of interventions. All recorded information was
subjective and qualitative. A sample of clients’
charts was randomly selected and examined in
April 2001. Descriptive statistics were utilized to
categorize clients’ perceptions of the benefits of
reflexology interventions with regard to indica-
tors and domains of QoL (Patrick & Ericson
1993).
Table 1 shows that the majority of clients
receiving reflexology interventions at ARC Can-
cer Support Centre were female, aged between 40
and 69 years and diagnosed with primary breast
cancer. Some clients had secondary cancer,
although stage of cancer was not noted in clients’
charts. The majority of clients were receiving or
had received either chemotherapy, radiotherapy
or a combination of both.
Table1Sociodemographic, disease and interventioninformation of 47 clients who received re£exologytreatments
%Gender Male 8.5
Female 91.5Age range (years) 20^29 2.1
30^39 17.040^49 27.750^59 25.560^69 25.570+ 2.1
Primary cancer type Breast 59.6Colon 12.8Lung 2.1Ovarian 8.5Uterine 4.3Squamous cell 4.3Leukaemia 2.1Hodgkins 2.1Thyroid 2.1Salivary 2.1
Cancer therapy Chemotherapy 29.8Radiotherapy 23.4Combination 29.8None 17
Previous re£exology interventions Yes 31.9No 63.8Not recorded 4.3
Number of re£exology treatments 1^5 386 487^12 8.512^16 4.3
Table 2 Perceived benef|ts of re£exology on Qol for 47 c
QoL indicators QoL domains
Functional status Psychological function
Physical function
Impairment Subjective complaints
No benef|ts/became ill
The QoL benefits illustrated in Table 2 were
recorded in clients’ charts either at the end of
treatment courses or following individual reflex-
ology treatment sessions. Clients reported im-
provements following reflexology interventions
related to two QoL indicators, i.e. functional
status and impairment (Patrick & Ericson 1993).
Clients’ perceived benefits can be classified as
related to these two QoL concepts with their
relevant domains. Functional status subsumes
both improved physical function (e.g. improved
sleep and increased energy) and psychological
function (e.g. relaxation, improved sense of self
and coping, and decrease in tension) while
impairment subsumes changes in experienced
symptoms and subjective complaints, such as
afforded pain relief and improved body function.
These overall improvements contribute to a third
QoL concept, that of perception of improved
health (Patrick & Erickson 1993, Ferrell et al.
1995).
Table 2 shows that, with regard to psycholo-
gical function, 34% of clients reported a sense of
relaxation, 6.4% experienced a decrease in
tension and sense of improved coping, while
29.8% of clients reported an enhanced sense of
self (defined as feeling ‘good’, more positive, and
improved well-being). With regard to improve-
ment in physical function, 29.8% of clients
reported an improvement in their sleep patterns
and 27.6% reported an increase in energy levels.
Table 2 also shows that 23% of clients con-
sidered that the reflexology interventions had
provided relief from the experience of pain, while
27.7% of clients considered that reflexology had
contributed to their improved body function. A
sample of clients’ subjective evaluations of the
benefits of reflexology, noted either during or
following the course of reflexology treatments, is
shown in Box 1.
Box 1 Sample of qualitative comments made byclients during or following re£exology treatments
K Never slept so wellK I am now sleeping through the nightK My energy levels are increasedK Headaches are almost gone or are coped withK Housework is not such an e¡ort
lients who received re£exology treatments
Perceived benef|ts (%)
Relaxation 34Improved sense of self 29.8Decrease in tension 6.4Improved coping 6.4Improved sleep 29.8Increased energy 27.6Improved body function 27.7Pain relief 23
12.8
72 ComplementaryTherapies in Nursing &Midwifery
DISCUSSION
Re£exology and the interactionof QoL indicators
QoL in the context of health can be construed as
the value assigned by individuals to the duration
of their survival which may be modified by
(1) functional status, (2) impairments, (3) health
perceptions, (4) opportunities and (5) death and
duration of life, through the influence of disease,
injury, treatment or policy. These five indicators
of QoL can be subdivided into domains of
attitudes, behaviours, perceptions and spheres of
action and thought (Patrick & Ericson 1993).
Domains of QoL for patients with cancer include
physical, psychological, social and spiritual well-
being (Fallowfield 1990, Ferrell et al. 1995).
Although different concepts and domains may
interact in classifying health status (Patrick &
Erickson 1993) the same interaction has implica-
tions for individual QoL. For example, in the
present study, clients’ perceptions of improved
physical function and reduced pain experience
following reflexology treatments (Table 2) may
have contributed to their improved sense of self
(defined as greater well-being and feeling more
positive) as experienced by 29.8% of clients, who
attributed these QoL improvements to their
reflexology interventions.
The possible benef|ts of re£exologyon functional status and impairmentin patients with cancer
In health-related QoL, while minor symptoms
may not impair psychological or social function,
major impairments and symptoms may cause
profound psychological and social dysfunction
(Patrick & Erickson 1993). Many of the symp-
toms associated with cancer may aggravate a
person’s pain experience, as may the metastatic
invasion of contiguous structures (Twycross
1994, Buckman 1996, Parris 1997). It is possible
for autonomic and somatosensory reactivity to
become a conditioned response to pain, which is
maintained and exacerbated by a pain–tension
cycle (Evers et al. 2001). The emotion most
frequently associated with acute pain is anxiety
(Sternbach 1976). Anxiety induced in a context
relevant to the patient’s fears, for example,
anxiety about medical procedures, may result in
a greater perception of pain (Breitbart et al.
1997). However, somatically oriented interven-
tions which alleviate cancer pain have also been
shown to reduce psychological distress, while
psychosocial interventions that are aimed at
relieving emotional distress have a profound
impact on nociception (Breitbart et al. 1997).
Patients with cancer frequently experience anxi-
ety and depression (Derogatis et al. 1983), some
with serious disturbance (Watson 1991, Breitbart
et al. 1997, Passik et al. 1997). Studies show that
reduced anxiety and depression is associated with
a reduction in pain experience, possibly through
an increase in pain threshold (O’Boyle et al.
1988). Mood and morale may have a circular
effect on the intensity of symptoms (Peteet et al.
1986).
In the context of the present study, a reduction
in anxiety and tension, together with the state of
relaxation experienced following the reflexology
intervention, may have impacted on the pain–
anxiety–tension cycle (Sloman 1995) as 23% of
clients stated that they experienced pain relief
following reflexology interventions, while 34% of
clients stated that they experienced relaxation,
29.8% had improved sleep, 27.6% of clients
experienced increased energy and 27.7% im-
proved body function (Table 2). These anecdotal
findings are consistent with findings in the
literature. A study by Stephenson et al. (2000)
of the effects of foot reflexology on anxiety and
pain in patients with breast and lung cancer
acting as their own control, found that anxiety
scores were significantly lower after foot reflex-
ology. A study by Hodgson (2000) of the impact
of reflexology interventions on the QoL of
patients receiving palliative care for cancer found
a significant difference between the reflexology
group and the group receiving placebo, the
former group reporting more perceived benefits
than the latter. A qualitative study by Coxon
(1998) of clients’ perceived benefits of reflexology
interventions for symptoms of either migraine,
headaches, back-pain, chronic tiredness and/or
arthritis showed that every respondent felt that
reflexology made a difference to how they felt
generally, with stated benefits including im-
proved perceived pain levels and improved
coping, reduced tiredness and greater sense of
relaxation. A qualitative study by Trousdell
(1996) showed that reflexology was considered
helpful in reducing and alleviating stress levels
and symptoms and increasing feelings of well-
being for a group of women experiencing mental
health problems.
While tumour and pain control are primary
intentions of conventional cancer treatment, side
effects of such treatment include fatigue, pain,
dyspnoea, physical decline, sexual and intimacy
issues and cognitive impairments, any of which
can erode the physical well-being of cancer
survivors (Ferrell et al. 1995). In the context of
the present study, patients might have experi-
enced possible side effects from conventional
cancer treatment (Oberst et al. 1991, Munkres et
al. 1992). It is possible that these side effects may
have reduced by the time reflexology interven-
tions were completed. Clients commented to the
reflexology therapists that they were aware of
‘good and bad’ days following chemotherapy
Clients’ perceptions of the benefits of re£exology 73
treatments, and that reflexology treatments
appeared to change the outcome of the bad
days.
Re£exology in the context of thebiopsychosocialmodel and QoL
The experience of cancer and associated treat-
ments may produce stressful appraisals involving
threat, harm and/or loss (Lazarus & Folkman
1984). Such appraisals may affect mood directly
and mediate the effects of symptom distress on
mood. The possible interaction of QoL indica-
tors and domains (i.e. the effect of improved
physical function on psychological well-being),
pertaining to the present anecdotal study, reflects
the focus of the biopsychosocial model on illness
as the result of a complex interaction of biolo-
gical, psychological and social variables. Illness
can be defined as a ‘subjective experience or self-
attribution’ referring to how the sick person and
members of his or her family and wider social
network receive, live with and respond to
symptoms and disability (Waddell 1992, Fordyce
1995, Turk 1996). There is considerable variation
in the ways that people in pain initially react to
symptoms and how these responses change as the
condition persists. Whereas it is assumed that
the concepts of pain and QoL are closely related,
the nature of this relationship has only recently
been fully acknowledged (Skevington 1995). The
anecdotal findings related to the present study
indicate the possible interaction of clients’
functional status and state of impairment, so
that increased ability to relax, reduced pain
experience, improved sleep and improved body
function may have enhanced clients’ coping
ability and sense of self (Table 2).
The perceived impact of re£exologyon coping and self-e¡icacy
Patients with cancer have to manage their
anxiety and pain as chronic problems (Stephen-
son et al. 2000). Cancer threatens not only
patients’ physical health but also their emotional
well-being (Jarrett et al. 1992). It has been shown
that the majority of patients with cancer use a
wide repertoire of coping responses (Jarrett et al.
1992). Following reflexology interventions in the
present study, 29.8% of clients reported en-
hanced sense of self, defined as ‘greater sense of
well-being’ and feeling ‘more positive,’ while
6.4% of clients reported improved coping
(Table 2). These findings again reflect the
possible interactive effects of QoL indicators
and domains (Patrick & Ericson 1993). The
capacity to perform daily routines and tasks
determines personal independence (Patrick &
Erickson 1993), a major determinant of sense of
self-efficacy, mastery and confidence (Bandura
1977, Schwarzer 1992). Self-efficacy, a belief in
personal ability, affects coping behaviours that
are chosen. In return, the outcomes of coping
behaviour possibly affect self-efficacy, in the
continuous cycle of feedback between cognitions
and behaviour (Zamble & Gekoski 1994).
Studies link beliefs in self-efficacy to more active
modes of coping with health-threatening events
(Pearlin & Schooler 1978, Strickland 1978). The
relaxation response is antagonistic to anxiety
(Benson 1976, Arathusik 1994, Sloman 1995,
Stephenson et al. 2000) and research shows that
there is a relationship between muscle tension,
autonomic hyperarousal, anxiety and pain (e.g.
Fishman & Loscales 1987). Perceived self-effi-
cacy in exercising control over potentially
threatening events plays a central role in
anxiety arousal and reduction (Bandura 1986).
The perceived benefits of reflexology interven-
tions (Table 2) may have impacted broadly on
clients’ well-being, perception of events, en-
hancement of clients’ coping ability and their
sense of self-efficacy (Bandura 1977, Pearlin &
Schooler 1978, Schwarzer 1992), while comments
shown in Box 1 demonstrate subjective evalua-
tions of clients’ sense of improvement on
individual QoL.
Developing a further study designfromthe f|ndings
The anecdotal findings described here help to
build understanding of the benefits of reflexology
for people with cancer and to identify areas for
more detailed and controlled research work
(Mackereth et al. 2000). However, the selection
of study designs for the evaluation of comple-
mentary therapies is recognized to be a complex
issue. Major considerations are outlined by
Liverani et al. (2000) especially with regard to
the debate about the use of double-blind,
controlled studies versus placebo, the Rando-
mised Controlled Trial (RCT) for such evalua-
tions. In countries where conventional
biomedicine is the basis of medical courses the
World Health Organization has indicated that
controlled trials are required to determine the
effectiveness of nonallopathic medicines. This
issue has resulted in two major stances. Stance
one is that taken by the Methodological Mani-
festo of the Working Group on Quantitative
Methods in Research on Complementary and
Alternative Medicine who have produced guide-
lines and recommendations acknowledging that
some types of investigation may not be amenable
to usual procedures of medical research and may
require different methodologies and statistical
approaches applied to particular problems.
Liverani et al. (2000) point out that RCTs are
effective in evaluating treatments in the acute
74 ComplementaryTherapies in Nursing &Midwifery
phases of disease, with easily identified endpoints
and that the philosophy underlying RCTs dis-
regards the relevance of subjective experience.
However, while the appropriateness of the
application of the classic RCT paradigm to the
evaluation of complementary therapies may be in
question, the necessity for evidence-based eva-
luation of all psychosocial interventions, includ-
ing complementary therapies is not in dispute.
Such evaluation should involve patients with
specific cancers, stratified on the basis of prog-
nostic variables, with precise management of the
intervention and outcome measures (Spiegel
1993). People with cancer undertake comple-
mentary therapies usually in the hope and
expectation of improvement in aspects of
QoL related to symptom control and well-being.
In this context (stance two) the WHO have
created a system to evaluate the impact of
conventional interventions and complementary
therapies upon a person’s QoL, rather than on
disease (WHOQOL Group 1995, cited in Liver-
ani et al. (2000)). A combination of qualitative
and quantitative methodologies applied to the
evaluation of QoL domains may contribute to a
resolution of some of the difficulties associated
with rigour.
The presence of a placebo effect in the evalua-
tion of complementary therapies is frequently
questioned (Skevington 1995). In particular,
‘placebo effects’ pose problems which cannot be
totally controlled even when subjects are ran-
domly assigned to experimental or control
groups. Where possible, adaptation of the RCT
to quasi-experimental methods, such as patients
acting as their own controls or utilization of
comparison of different therapies in evaluations
of complementary therapies, may help to over-
come some of the problems associated with
placebo effects.
CONCLUSION
The emphasis of psychosocial interventions for
patients with cancer has come about because of
(1) the recognition of the intensity of symptoms
associated with both the illness and side effects of
cancer treatment and (2) the requirement for
facilitation of optimal function and life satis-
faction for the person undergoing the illness
experience and/or associated treatment. Conven-
tional medical interventions alone frequently do
not meet the QoL needs of this patient popula-
tion, thus complementary therapies, together
with other psychosocial interventions which
may enhance the QoL of people with cancer,
need to be considered (Watson 1983, Spiegel
1993, Fallowfield 1995, Hodgson 2000). Reflex-
ology is used to treat people with a broad range
of conditions and much of the literature evaluat-
ing the benefits of reflexology is anecdotal. While
there are many reports in the literature outlining
perceived improvements in various domains of
QoL for people with a wide range of illnesses,
including cancer, more rigorous evaluation is
essential to allow practice to be based upon
knowledge and to justify the use of reflexology
interventions for people with cancer (Botting
1997). The anecdotal findings of the benefits of
reflexology for a group of people with cancer
presented here may serve as a guide for further,
research-based, evaluation with the use of a
specifically designed and validated measurement
tool and a carefully considered and appropriate
research design.
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