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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