Osteoarthritis (OA) is one of the most common joint disorders [1]. At the core of osteoarthritis are pain and swelling, as well as distortion and dysfunction of a given joint [2]. Chronic pain is a complex phenomenon that requires a multidirectional healing process, in which both physical and mental bases must be taken into account [3]. In Poland as well as in other countries, osteoarthritis is regarded not only as a medical but also social and economic issue. Therefore, the World Health Organization declared the years 2000 to 2010 to be the Bone and Joint Decade, and the United States Congress proclaimed this period the Decade of Pain Control and Research [4]. Among patients suffering from chronic pain due to osteoarthritis, one group is especially noteworthy. The group in question consists of elderly patients with restrictions and medically declared contraindications for pharmacotherapy in the form of analgesics [5].
Presented in this article is the application of reflexology in individuals with chronic joint pain. Reflexology is the study of reflex points (reflex zones), i.e. points located on the feet and hands. They correspond to specific organs or parts of the body [6]. The presence of any disorder or medical condition results in hypersensitivity in these zones, and thus provides information on the state of the whole body or a given organ. Reflexology involves stimulating pressure points located on the feet, hands, head and ears using appropriate pressure techniques. Application of controlled pressure on appropriate pressure points results in the stimulation of the nervous system and improves blood circulation which, in turn, helps to regulate bodily functions [7].
Reflexology Association of America (RAA) defines reflexology as a non-invasive, complementary method involving the application of variable pressure applied to points located on the feet, palms and outer ear that are predefined on a map of body reflexes. According to the Random House Dictionary, reflexology is a system of massaging specific areas of the foot or sometimes the hand in order to promote healing, relieve stress, etc., in other parts of the body. The International Dictionary of Medicine and Biology states that in reflexology the therapeutic effect is achieved by stimulation or irritation at a distance from the area treated [8].
Reflexology is regarded as an alternative and complementary therapy of stress and tension that encourages the flow of blood and contributes to maintaining proper homeostasis. There are several theories that attempt to explain how this therapy impacts body health [9]. Reflexology promotes healing by stimulating zones called reflexes located on the surface of the skin, which causes the release of endorphins by brain cells. These substances contribute to the proper functioning of the heart and assist proper hormonal activity. Moreover, endorphins help reduce pain and control muscle tension as well as mood and emotions [10]. The impact of reflexology is also reflected in improved blood and lymph circulation [11]. Foot reflexology has a soothing and relaxing effect, and reduces tension and stress associated with physical issues. This, in turn, influences the responses from the autonomic system, and affects hormonal balance and the immune system. From a psychological standpoint, reflexology is a form of showing concern and care for patients [9].
Regardless of the condition and pattern of a given patient’s illness or disorder, all zones and reflexes are checked. Once the initial diagnosis is made, the first session is carried out. The first procedure is performed with great care and sensitivity and the patient’s reaction is constantly monitored [12].
The subsequent sessions are carried out in a similar fashion. The therapeutic session is approximately 45 minutes long. Each session consists of 3 stages. The first stage is the preparatory stage, in which the patient is prepared for the actual treatment by relieving the body of excess muscle tension, as well as getting used to the touch of the reflexologist. The specialist warms up the patient’s feet and helps him relax. [7]. During the main part of the treatment, the therapist works on individual receptors by applying appropriate therapeutic techniques in the correct order. During the final stage, the reflexologist performs a relaxing foot massage, helping the patient achieve the state of deep relaxation. The number of reflexology sessions and their duration depend primarily on the patient’s condition. Factors such as the history and characteristics of a given condition, as well as the patient’s age, lifestyle, attitude towards therapy and reactions also play an important part in the healing process. There are, however, several rules regarding the number of recommended therapeutic sessions. The first diagnostic session takes approximately an hour. Subsequent sessions are relatively shorter and run for approximately 30-50 minutes. If the session is too short, it will not provide the body with a stimulus strong enough to trigger the regeneration process. On the other hand, too long a treatment provides the body with excessive stimulation, which can result in an excessive release of toxins, as well as discomfort on the part of the patient. A series of reflexology treatments should consist of 8-12 sessions, once or twice a week. In practice, it is recommended to start the therapy with two sessions per week indispensable for achieving a minimum improvement in the patient’s condition and subsequently to gradually decrease the session frequency [13]. Disorders and limitations of the musculoskeletal system may also be indicators for the application of this form of therapeutic treatment [11].
There are no known cases or reports regarding negative impact of reflexology treatment on patients’ health. There exists, however, a group of contraindications to applying this method. These can be divided into absolute and relative contraindications. The first group includes acute inflammatory condition of the venous or lymphatic system, post-transplant condition, aneurysms, high fever infections and mental disorders such as manic depression and schizophrenia. Relative contraindications include complex regional pain syndrome (Sudeck’s syndrome), gangrene, eczema, mycosis or rheumatoid disorders in acute condition. Other contraindications also include high-risk pregnancies [12].
The aim of this study was to evaluate the impact of foot reflexology treatment on pain and vitality level in individuals with osteoarthritis. Taking this into consideration, the following research questions were formulated:
Did the vitality level and daily activity of the patient change after a series of reflexology sessions?
Did the number of analgesics taken orally by the study participants change after a series of reflexology sessions?
Did the severity of arthralgia change after a series of reflexology sessions?
The study was conducted on a group 20 individuals (16 women and 4 men) aged 41-76 (mean age 60.9 ± 10.06) who suffered from osteoarthritis. The study participants visited the reflexology centre in Markowa and expressed their willingness to undergo a series of reflexology sessions. The biometric data of participants are shown in Table 1.
Biometric data of participants
| Parametr / Parameter | Statystyki opisowe / Descriptive statistics | |||
|---|---|---|---|---|
| Me | Min. | Max. | ||
| Masa ciała / Body mass [kg] | 81.80 ± 15.18 | 79.00 | 65.00 | 120.00 |
| Wzrost / Height [cm] | 169 ± 0.09 | 170 | 153 | 180 |
| BMI [kg/m2] | 28.61 ± 5.58 | 27.04 | 23.03 | 42.52 |
The study inclusion criteria: pain due to osteoarthritis of the hip joint, informed consent of participants to take part in the study. Exclusion criteria: an acute inflammatory condition of the venous or lymphatic system, post-transplant condition, aneurysms, melanoma, high fever infections, mental disorders, Sudeck’s syndrome, dermatological diseases of the feet, acute rheumatoid disorders and high-risk pregnancies.
The study was conducted prior to the therapy and after a series of 8 sessions. Each session consisted of three stages: the preparatory stage, the main stage, during which the therapist worked on specific receptors, and the final stage – a relaxing massage. During the preparatory stage, the therapist made visual as well as palpation assessment of the foot and relaxed the Achilles tendon, the ankle joint and the foot. During the main stage, the therapist worked on the meridians of the gallbladder on both feet, as well as both heels. These areas correspond to disorders in the hip joint and pelvic area. The kneading method was applied during this stage. The therapist performed all techniques using the thumb and index finger. The relaxation massage was performed by means of deep breathing technique incorporating the solar plexus. In total, the session lasted 45 minutes.
The research tools used in the study were the WOMAC (Western Ontario and McMaster Osteoarthritis Index) questionnaire [14] as well as the NRS (Numerical Rating Scale). The WOMAC questionnaire includes 24 parameters. This is a research tool originally developed by Bellamy in 1982 and it has been modified several times since then. It is used to assess the level of disability of patients suffering from osteoarthritis, with a particular focus on the knee and hip joints. It covers the assessment of the severity of pain while the patient is lying flat, getting up, sitting and walking, as well as during morning joint stiffness and day joint stiffness, and the evaluation of the level of difficulty regarding bending, walking, climbing the stairs, putting on socks, etc. The questionnaire parameters are divided into the following three groups: pain, stiffness, and function. Each question is accompanied by a five-grade scale (from 0 to 4 points, respectively), depending on the level of difficulty in performing a given activity. For each of the components of the group, the number of points is defined. The results are as follows: 0-20 points – pain, 0-8 points – stiffness, 0-68 points – function. The sum of all points constitutes an overall assessment of the patient’s condition (0-96 points). The more points the patient gets, the more severe the condition. A standard version of the questionnaire covers symptoms experienced by the patient within the last 24 hours [15].
The statistical analysis of collected data was carried out in Statistica 10.0. For the analysis of variables, both parametric and nonparametric tests were used. The choice of the parametric test depended on the fulfillment of its basic assumptions, i.e., the conformity in the distribution of variables tested with universally acknowledged distribution of variables (data), which was verified by applying the Shapiro-Wilk test. In order to assess differences in the mean level of the statistical feature in two populations, the t-Student test for independent variables was applied. In the alternative assessment, the non-parametric Mann-Whitney U test was employed. The level of statistical significance was established at p <0.05.
The analysis revealed that in 85% of the cases (17 respondents) the pain of the hip joint persisted for more than 3 years. 80% of the respondents admitted to having undergone conventional therapeutic treatments such as pharmacotherapy, kinesiotherapy, physiotherapy or therapeutic massage. They had not used the methods of alternative medicine before.
After the treatment, the researchers observed an improvement in the average result obtained from the WOMAC questionnaire. The results are statistically significant and they are presented in Table 2.
Analysis of data obtained from the WOMAC questionnaire
| WOMAC | Statystyki opisowe / Descriptive statistics | |||
|---|---|---|---|---|
| Me | Min. | Max. | ||
| Przed terapią / Before the therapy | 44±18,78 | 79 | 14 | 42 |
| Po terapii / After the therapy | 30±14,59 | 57 | 11 | 28 |
| Istotność statystyczna / Statistical significance | t=5,52 p=0,0000 | |||
Having analysed the results obtained from the WOMAC questionnaire regarding the condition of the respondents prior to and after the therapy, the authors observed a decrease in pain intensity and an improvement in everyday physical activities such as climbing up and down the stairs, walking, bending or getting dressed. Statistically significant values are presented in Table 3.
The ‘Pain’ area in the WOMAC questionnaire
| Ból wg WOMAC / Pain acc. to WOMAC | Statystyki opisowe / Descriptive statistics | |||
|---|---|---|---|---|
| Me | Min. | Max. | ||
| Przed terapią / Before the therapy | 9 ± 3,97 | 15 | 3 | 8 |
| Po terapii / After the therapy | 5 ± 3,05 | 11 | 1 | 5 |
| Istotność statystyczna / Statistical significance | t=6,30 p<0,001 | |||
| Funkcja wg WOMAC | Me | Min. | Max. | |
| Przed terapią / Before the therapy | 32 ± 13,93 | 54 | 9 | 30 |
| Po terapii / After the therapy | 23 ± 11,43 | 43 | 7 | 21 |
| Istotność statystyczna / Statistical significance | t=4,89 p=0,0001 | |||
The applied therapeutic treatment had a noticeable impact on patients resulting in the reduction of the amount of administered analgesics (p = 0.006). The patients also reported an improvement in the quality of sleep. Prior to the reflexology therapy, over 1/3 of the patients involved in the study described the quality of their sleep as good and only 5% of them described it as very good. Twenty-five percent of the respondents described the quality of their sleep as good and the same number assessed it as bad, while 15% described it as very bad. After the therapy, the number of people who claimed that the quality of their sleep was very bad decreased to 0. There was also a significant decrease in the number of people who admitted to sleeping poorly. The highest percentage increase was recorded in the group of people who described the quality of their sleep as good and very good. The researchers observed a statistically significant difference while comparing the number of sleepless nights due to pain and discomfort. Prior to the therapy, this value had been established at 2.5, and after the therapy, this value decreased to 0.9. The results are statistically significant at the level of p = 0.0033. Eightyfive percent of respondents found the reflexology treatment to be effective in relieving pain.
Our findings showed that the patients found reflexology to be an effective therapeutic method of relieving pain, which also has a positive impact on their vitality and results in an improved level of functionality in their everyday lives. Implementation of reflexology treatments resulted in a significant reduction of the functional limitations of the patients as well as in a significant decrease in the level of pain and stiffness of joints. Results showing differences in the level of joint pain measured on the NRS scale were statistically significant, which proves the effectiveness of reflexology in reducing arthralgia. There was also a statistically significant correlation between the quality of sleep of the respondents prior to and after the therapy.
Measurements of pain intensity in the case of patients with osteoarthritis were performed on the last day of the therapy, so high effectiveness of the reflexology treatment in relieving pain may be associated with short observation time. It cannot be determined whether the pain reduction will last. The positive effect of the reflexology treatment may be related to the placebo effect and the lack of side effects experienced by the respondents.
Reflexology is an alternative form of therapy considered effective in relieving pain. Alternative medicine treatments such as reflexology are considered unscientific, short-term remedies undertaken exclusively by the elderly or less educated people from lower social classes [16]. The effectiveness of reflexology in reducing pain was investigated with the help of a group of individuals suffering from lumbosacral hernia. After three reflexology sessions, more than half of the subjects in the aforementioned group experienced a decrease in pain intensity [17]. The researchers found that in the case of patients with rheumatoid arthritis who underwent 7 reflexology sessions, pain intensity in the knee joint as well as the swelling of joints decreased after 2-4 treatments. The researchers also observed beneficial effects of foot reflexology treatments on the blood and lymph circulation, strengthening of the immune system, and a decrease in the level of ischemia and hypoxia in joints impacted by rheumatoid arthritis. However, caution is advised when applying this method in an acute form of the disease [18]. Research on the impact of reflexology on pain and the quality of life of patients with rheumatoid arthritis has proven its efficacy in reducing pain and improving the quality of life and overall condition, irrespective of the age of patients or duration of a given disorder. The authors recommend introducing this method into the curriculum and teaching programs of medicine and nursing students as well as postgraduate staff development programs. They also point to the need for further research to evaluate the efficacy of this method in the treatment of pain in the case of geriatric patients and patients suffering from pain due to chronic conditions [19]. Research carried out by Movaghar et al., regarding the evaluation of the effect of reflexology treatments on the reduction in chronic pain of the spinal column, indicate a significant decrease in pain intensity [20–22]. Poole et al. also investigated the therapeutic effect of reflexology in patients with spinal pain. In their opinion, reflexology is an auxiliary method in the treatment of back pain and it should not be treated as an independent form of therapy [22]. Clinical studies confirm that the reflexology treatment resulted in an improvement of the overall condition of patients and helped reduce the intake of administered medications [23]. In the research conducted by Kompinski et al. regarding the therapeutic and diagnostic effects of reflexology, a decrease in pain intensity in major joints (knee, hip, shoulder, elbow) was observed. A significant percentage of individuals involved in the study experienced this effect of reflexology treatment.
In the same study, the researchers pointed to beneficial effects of reflexology on the quality of sleep [12]. The results of our research confirm this correlation. No negative reactions to reflexology treatment were observed among patients. The authors of the studies referred to above recommend reflexology as a complementary form of therapy in working with patients with various ailments or symptoms, as well as an effective therapeutic method for sleep disorders. Asltoghiria et al. found a correlation between reflexology sessions and improvement in the quality of sleep [24]. Our findings confirm this pattern, as the quality of sleep among respondents improved significantly after the therapy. There was also a noticeable decrease in the number of hours without sleep.
In recent years, reflexology of the feet has been gaining more and more recognition among patients and medical professionals as one of the methods of alternative medicine [25]. Due to the increased interest in this method of therapy, any attempts whose goal is to develop a reliable, objective and scientific method of evaluation of the effectiveness of reflexology is highly desirable and appropriate.
The matter of critical importance is to find an effective method of relieving pain other than pharmacotherapy. The effectiveness of reflexology confirmed in the above-mentioned studies points to the need for further research aimed at finding an appropriate method of patient treatment. It is worth noting, however, that reflexology ought to be used as a complementary method of therapy, improving the overall functional state of patients and enhancing the analgesic effect. Reflexology cannot be regarded as the primary method of treatment for osteoarthritis, as it does not directly affect the source of the disorder.
This study is a pilot project. In order to confirm the obtained results regarding the decrease in pain intensity in patients with osteoarthritis and the improvement in the quality of their lives, the study will be carried out on a larger group of patients with long-term observation and analysis of results. In the planning of subsequent research projects, the diversity of given groups of patients in terms of age and severity of disorders ought to be taken into account. The application of objective methods of assessment with regard to the effects of therapy would also be crucial for future research on this subject. Moreover, in this instance, it appears significant to apply a randomized, double-blind trial. The review of the current scientific literature on the subject shows the need for further research, as there are very few reliable sources dealing with the topic of the impact of reflexology on pain.
Respondents involved in the study regard reflexology as an effective method of relieving pain as they experienced a significant decrease in pain intensity.
Reflexology has a beneficial effect on the level of vitality and activity of patients with osteoarthritis and it reduces the intake of administered analgesics.