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Effects of reflexology on fibromyalgia symptoms: A multiple case study
Complementary Therapies in Clinical Practice 16 (2010) 167–172
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Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctnm
Effects of reflexology on fibromyalgia symptoms: A multiple case study Thora Jenny Gunnarsdottir a, *, c, Cynthia Peden-McAlpine b, d a b
Faculty of Nursing, University of Iceland, Reykjavik, Iceland University of Minnesota, School of Nursing, MN, USA
a b s t r a c t Keywords: Reflexology Fibromyalgia syndrome Multiple case study Nursing Symptom
Purpose: To explore the effects of reflexology on pain and other symptoms in women with fibromyalgia syndrome [FM]. Methods: Multiple case study method as developed by Stake was used to investigate the effects of reflexology on six cases of women with FM which were given ten sessions of weekly reflexology. Data were collected with observation, interviews and diary and then analyzed within cases and across cases. Results: Reflexology affected the symptom of pain in multiple areas such as head, neck and arms. Pain started to isolate and decrease. Conclusion: Reflexology may be helpful to decrease fibromyalgia symptoms. Qualitative research methods and individually tailored interventions are important when researching complementary and alternative therapies. Ó 2010 Elsevier Ltd. All rights reserved.
1. Introduction Fibromyalgia syndrome (FM) is a rheumatologic syndrome, manifested as a chronic disease with diffuse musculoskeletal aching and soreness, accompanied by poor sleep, fatigue, and morning stiffness.1 The etiology in FM is not fully known. Muscle abnormalities, sleep disturbances, and a biochemical unbalanced metabolism have all been considered as playing a part in FM.2 Fibromyalgia tends to be more common among women than men, with female prevalence ranging from 73% to 88%.2 The impact of this disease is severe for patients, both physically and economically and studies have found that 44% of patients with FM may be unable to perform household tasks without assistance.3 FM patients often feel disabled by fatigue and may not be able to hold a full-time job or perform everyday activities.3 Conventional medicine falls short in providing expected sustained relief from pain in patients with FM.4 No treatment interventions, whether pharmacological,5 lifestyle manipulations,6,7 or
* Corresponding author. Tel.: þ354 5254982; fax: þ354 5254963. E-mail addresses: [email protected] (T.J. Gunnarsdottir), [email protected] (C. Peden-McAlpine). c Thora J. Gunnarsdottir is assistant professor at the Faculty of Nursing at the University of Iceland. Her program of research is in complementary and alternative therapies in nursing practice. d Cynthia Peden-McAlpine is associate professor at the University of Minnesota, School of Nursing. Her program of research includes expertise in qualitative methodology, clinical judgment and reflective practice strategies and the inclusion of families in the end of live care. 1744-3881/$ – see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2010.01.006
nonpharmacological agents8 have been found to be universally successful in improving the symptoms of FM. Patients with FM have been reported to have explored complementary and alternative therapies (CAT).9 An assessment of the use and satisfaction with alternative medicine practices used by FM patients and a comparison of FM to other rheumatology patients were done in a study in Canada.10 The findings indicated that 73 (91%) of FM patients identified alternative medicine use, compared to 140 (63%) of control patients. Few rigorous studies have demonstrated the effects of reflexology as an effective treatment for chronic symptoms. 2. Background Reflexology is a specific pressure technique that works on precise reflex points of the feet, based on the premise that reflex areas on the feet correspond to all body parts. Because the feet represent a microcosm of the body, all organs, glands, and other body parts are laid out in a similar arrangement on the feet.11 The literature implies that reflexology is useful for achieving and maintaining health, enhancing wellbeing, and helpful for relieving the symptoms of illness and disease.12,13 Studies of reflexology have been reported to help to alleviate the effects of stress by inducing deep relaxation so one’s body can regain homeostasis,11,14 decrease anxiety in patients with breast and lung cancer,15 increase comfort and quality of life in patients with cancer16 and Multiple Sclerosis.17 It has also been shown to help migraine patients relief headache and reduce pain medication intake,18 and relieve symptoms of multiple sclerosis.17,19,20 The
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effect of reflexology on symptoms of fibromyalgia has not been reported in previous studies. A recent systematic review of the efficacy of reflexology states that there is no evidence for any specific effect of reflexology in any conditions except of urinary symptoms associated with multiple sclerosis.21 The authors did therefore not recommend routine provision of reflexology. However in a study of the effects of reflexology on patients undergoing coronary artery bypass graft surgery it is suggested that reflexology should be tailored to individual needs and research methods used that allow for capturing its holistic nature.22 3. Methods 3.1. Study design Given the questionable evidence base of the state of reflexology research and the need to allow for individually based treatments led the researchers to do a systematic and inductive study of reflexology, using a qualitative design; the multiple case study method as described by Robert Stake.23 In this study, each case consists of one participant suffering from Fibromyalgia Syndrome (FM) who undergoes 10 reflexology sessions. Each case was looked at individually and then the cases were collapsed together in order to make assertions about reflexology for FM patients. Each case to be studied has its own problems, and stories to tell but the main research interest is in the evaluation of multiple cases. The main research question focused on was: Do the participants experience changes of pain or other symptoms during multiple reflexology treatments in the study period? 3.1.1. Procedures and setting An MD who specializes in treating patients with FM recruited eligible participants, men or women, who were diagnosed with FM according to the American College of Rheumatology criteria (Table 1). Six women with FM took part in the study. The youngest one 27 years old, and the oldest 55 yr, with a mean age of 39 years. Four of them were married with children. They had all been recently diagnosed with FM, although some of them had been battling with symptoms for years. An average of four to ten cases is thought to be most appropriate for a multiple case study.23 The necessary steps to obtain permission and authorization through the Institutional Review Board (IRB) at the University of Minnesota, from Protection of Personal Data in Iceland, and from The National Bioethics Committee in Iceland were obtained. Written consent was also obtained from all participants involved in the study. The reflexology sessions took part in a reflexology clinic. One reflexologist administered all reflexology treatments in the study in order to reduce any possible inter-rater reliability issues. All of the areas in the feet were assessed and worked on during the first session. In the second session, a comprehensive assessment was done again on both feet, and each participant was asked specifically about his/her state in connection to the findings from the former session. These findings guided the second session; whatever was Table 1 Guidelines for inclusion/exclusion. 18 years or older Native speaking Diagnosed with FM Having both feet and all toes intact and free from wounds No use of other complementary or alternative therapies during study Has no other significant health problem unrelated to FM No use of sleep medications No use of sedative or sleeping medications Referred by MD specialist in FM
found to be imbalanced was worked on, depending on each participant. The 10 sessions proceeded in the following manner: a period of 45 min was estimated to be adequate time to perform reflexology on both feet; however, extra time was allowed for specific work on areas needing further care. At the end of each session, the participant relaxed for at least 10–15 min. 4. Data collection Data were collected trough three major sources; interviews, observation and diary. The purpose of the interviews was to serve as a resource for developing a richer and deeper understanding of how the women experienced the effects of reflexology on their symptom experience, specifically on pain. All interviews were conducted privately, tape-recorded and transcribed. The researcher was present in the field during all of the sessions, recording and making field notes of what was taking place. The participants filled out a symptom diary for 13 weeks. The diary started one week before the first reflexology session and the diary writing finished two weeks after the last reflexology session. During each day of the study the participants were to write down any specific notions of symptoms such as their reflections on the quality of their sleep, medication intake and any sensations of pain or any other aggravating symptoms or benefits. If they were experiencing pain, they were asked to mark all of the different sites of their pain on a diagram of a body and to evaluate the strength of the pain at each site using a Numerical Rating Scale (NRS). The zero point indicates ‘‘no pain at all’’ while 10 indicates ‘‘the worst pain imaginable.’’ The participants were asked to mark a score on the line corresponding to the amount of pain sensation they experienced. 4.1. Data analysis Data were analyzed both within case and cross cases.23 In the within case analysis all of the data for each case were reviewed, and a general description of the experience of reflexology on pain and symptoms was recorded. Each participant’s pain was mapped out to give a graphic format of how it was experienced during the study according to the diary. The main activity of a cross-case analysis consisted of reading the case reports as a whole, all of the original data, with special attention to the commonalities, uniqueness, confusions, contraindications and missing information between the cases regarding any salient issues. 5. Results 5.1. Within case analysis A very short description is given for each participant that focuses on the experience of pain as it was reflected during the study and a graph of pain experience of each participant is provided. The first participant Anna has been battling symptoms of pain with fatigue for over twenty years. She has difficulty describing her pain. Some days it is only light obtuse pain, but other days, it feels like a throbbing pain. Anna described several changes in pain that had occurred during the sessions. She actually felt worse during the first weeks of the study especially having bad headaches and neck pain during the first two weeks and she had to try hard to keep herself from taking medications which she didn’t want to do. In session five when the therapist was working to relief her headache, Anna noticed how the fog had disappeared from her head, making herself feel mentally ‘‘lighter.’’ She took deep breaths and then said, ‘‘The veil has gone from my head; it is just gone.’’ She could feel how it suddenly had gotten lighter and the heaviness over her head
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had disappeared. This heavy sensation did not return during the study period. The diagram of pain over the study period shows this well for Anna (Fig. 1). At the end of the study she reported less pain in her head, arms, hips and elbows. Additionally, the pain in her hip joints and in her fingers became much better and her perspiration had become much less than before. What did not change was the pain around the coccyx. Betsy described her pain as a throbbing-like sensation of being stabbed in several places by a knife, but also experienced stiffness and numbness, especially in the mornings. As evident in the diagram made from Betsy’s experience of pain during the study (Fig. 2) she first gets worse but then much better around week seven and eight. She describes how her stiffness subsides and she began to feel less irritation in her body. Therefore she decided to take on another job just because she was feeling so good. At the end of the study she was getting worse again, her stomach was in bad shape and the stiffness in her joints was back and she blamed her condition on the new job, additional stress, heavier workloads and wrong diet. Connie had chronic pain in her neck, and shoulders while experiencing numbness in her arms. In the last few months before the study, her condition has gotten increasingly worse. As shown in the diagram of the pain during the study it was evident that after the eighth session, things were dramatically turning better for her (Fig. 3). At the end of the study she was feeling much better than before the study. At about week nine she said, ‘‘This has been one of my best weeks.’’ The numbness was less and had almost disappeared from her arms; in addition, her headaches were less frequent. The fourth participant Donna was hit in a car accident and experienced whiplash; soon thereafter her body gradually became worse. In her own words, she said, ‘‘I remember that at first I was very tired and had no energy and was not able to get going. Then just very slowly, I started to stiffen up in one area after another and couldn’t move as easily. But this just happened very slowly after the accident over the period of a year. It started at the back of my neck, but then started to move down the body to my arms and down my shoulders and then to my chest area. Now it is also in my lower back.’’ For Donna, pain changed during the study. She acknowledged this in her diary ‘‘The first weeks were tough, so it was an uphill battle. Then around week seven, it started to go down again, and then I suddenly realized that I was feeling better, both physically and emotionally. There was less pain and better sleep and more energy than I had before I started [the study]. It just suddenly
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occurred to me. I was going over my diary and making sure that I had everything there, and then suddenly I noticed VOW!! And it kept on being that way. I mean, with having Fibromyalgia and all that, I would be happy if I could just be in this place and not go downhill again.’’ She also stated that during the study when she was overloaded with work and stress, she was in much better shape to deal with it and concentrate on it, despite being tired. The week between sessions eight and nine were the best for Donna in a long time (Fig. 4). Ella experienced pain in her back and at the back of head that bothers her everyday and frequently gets migraine headaches. She stated that her symptoms started to appear some fifteen years ago after the car accident. During the study it is evident in the graph from Ella that there is not much change in pain from the first to the last sessions (Fig. 5). Over the sessions, not much progress occurred; in fact, for the whole time Ella experienced the same pain in the same spots throughout the study. Sometimes there was also pain in her elbows. When asked about her migraine headaches, she suddenly realized that they had not been bothering her for over three months, which was a relatively long period of time. In fact, her headaches had not bothered her since starting her reflexology sessions. At the beginning of the study Ella took on a new job which became a more increased workload than expected. Although she did not express any changes during the study she comments on how despite her workload she felt better than expected. Fanny has a long story of pain and chronic fatigue. The pain is all over the body and she describes it as heavy burdensome sore and overwhelming in her head, shoulders, back and arms. In summary, the reflexology sessions did not do much for Fanny. After the study started, there were some changes and benefits that came and went quickly. She noticed some relief of the ‘‘helmet’’ on her head and some lightness in other areas. However, this relief never lasted long
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enough, and usually not throughout the day of the session. All activities during the day affected her wellbeing. If she felt better after a session, the benefits would disappear while she drove home because merely driving a car increased her pain. It was obvious that her condition was very severe and reflexology did not have much to offer to her. The reason for her graph being different is due to the aggressiveness of the pain which was constantly fluctuating each day (Fig. 6). 5.2. Cross-case analysis Although the women had different stories to tell, they all seemed to have suffered from an accident or shock, or some traumatic experience that they identified as a starting point of their FM. Pain was sensed the most prominent symptom the women sense as a part of FM. They described their pain starting in isolated areas, then traveling from one area to another. Some women remembered how the pain progressed by starting in one area in the body, then beginning to show up in other areas, until the entire body had somehow become affected. The pain was felt mostly in the joints and muscles, but was described as different from muscle soreness. Some painful areas responded to better to reflexology, such as headaches, pain in shoulders, arms and the neck, as evident by lessening pain strength or the pain disappearing. At specific sites, the pain remained in the joints, the fingers, or the coccyx, depending on each individual. However at most of those sites the level of pain decreased during the study. The pain is also described in the graphs of pain as drawn by the women in each case. The graphs were verified with their diaries to make sure that what they had reflected in writing was corroborated by the figure above. When examining the lines in the graphs, the subjects who showed decreased pain on the graph all started to get
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worse first. For most of them, this worsening was immediately after the first session, while for others, it was an ongoing experience, up to the seventh session. They described their condition as either being worse in pain or feeling worse in their body. There were times when some considered withdrawing from the study but decided to hang on and see what happened. It is interesting to see that at approximately the sixth to eighth weeks, four of the six women started to show dramatic changes in their wellbeing and felt much better rather suddenly during the eighth and ninth weeks. Sleep disturbance is a symptom frequently seen in FM. Therefore, a specific section in the diary was used to record the participants’ sleep patterns for each day. They described their sleep as not being enough, as waking up without feeling adequately rested and as awakening with stiffness and pain. At the end of the study, the patterns of sleep did not change much for any of the participants. Their sleep rhythms were similar throughout the study, and they interpreted these rhythms as ‘‘not good enough.’’ The findings in each case indicated that the quality of sleep depended more on what was happening in their lives rather than on the disease itself. The most significant factors affecting their sleep were disturbances by children, their work schedule, stress or keeping themselves occupied instead of going to bed. Some other health problems or FM symptoms responded to the reflexology. This finding was evident for migraine headaches, edema, and fecal elimination problems. Migraine headaches, which were a common problem for two of the participants, did not happen during the study. Also, if a women had the tendency to get edema in their legs or other areas, then this commonly decreased during the study period. However, these effects did not last long after the study period; moreover, their edema often fluctuated along with the women’s menstrual cycles, becoming worse the week before menstruation. Fecal elimination became more normal for some, and they described their stools becoming looser and more frequent. Events going on in their lives definitely affected the way they felt during the study. All but one of the participants was working outside the home, and their work affected their FM symptoms. However, it was interesting that several of the women reported that they were able to take on more responsibilities or were able to increase their workload during the study period. Five of the women talked about how they did not feel as tired as they had before the study started; indeed, they did not feel as ‘‘loaded’’ with their symptoms, even though their workloads or stressors had increased. Three participants (Anna, Connie and Donna) detected benefits after the first few sessions, which seemed to increase their control over their FM symptoms, enabling them to cope better. That sentiment lasted throughout the study for these three participants. Two of the women (Betsy and Ella) began new jobs during the study period. At the end of the study they alluded to how that workload affected their symptoms and wellbeing and increased their stress seriously. Betsy showed improved wellbeing at first, but
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her condition worsened as her workload and stress increased. Ella’s status did not change over the study period, showing also that she did not get any worse. She also described how frustrating it was not to find any benefits from the reflexology and lost interest in what was going on in the sessions over time. For the sixth participant (Fanny), it was obvious right at the beginning that her symptoms were very serious, and her entire days had to be scheduled around her pain. It was difficult for her to add the sessions to her schedule, as she already had other appointments during the week. Although she could relax during most of the sessions, the reflexology effects had completely disappeared on the way home, just by stress from driving or because the weather was cold. 6. Discussion The study findings demonstrated that pain was the most prevalent symptom and was evident by how the women recorded their pain each day in their diaries and how they were feeling at different sites in their bodies during the day. The pain was sensed as more severe than muscle soreness, although it was mostly sensed in the muscles and joints. The women described the pain as all over, sore, numb, aching and hurting; they narrated how it was always present, constant and wandering from one location to another, similar to previously documented fibromyalgia pain24 and as both mental and physical.25 The pain changed during the study and started to become more isolated and decreased in severity in four out of six cases. The areas that responded best were the head, shoulders, neck and arms. This phenomenon was most evident after the seventh or eighth sessions, indicating that several sessions of reflexology are needed in order to show evidence of lasting benefits. The findings demonstrated that the participants experienced some pain relief that increased their wellbeing. Pain at specific sites decreased, especially headaches and migraine headaches. This result reflects findings from two other studies of reflexology, in which patients described less pain following reflexology.18,26 In general, pain in some areas did not change during this study; for example, pain in joints. It may have been that they had become too chronic or needed more reflexology sessions in order to have any effect. Benefits of reflexology for other symptoms such as edema and fecal elimination have been reported before.17 Looking at the figures of pain for each participant it is interesting that before the women got better they got worse. This may be a factor in healing and needs to be analyzed further. The findings supported the theoretical framework behind reflexology, which aims to heal and to restore balance and wholeness. When the women felt the process of recovery and repair take place, they felt more whole and gained a better sense of coherence. In four cases, the pain decreased in specific places. These phenomena took place as the women started showing dramatic changes between the sixth to eighth sessions. In the study by Launso¨ et al.,18 in depth interviews were conducted with 10 of the participants. The analysis of the interviews demonstrated that patients who considered themselves cured based this on their involvement with reflexology and the fact that they did a lot of thinking about their health and their understanding of the headache changed. They recognized the headache as part of the body and therefore related to a mind–body connection. The women were all eager to try reflexology, as they had previously been trying other CATs to relief symptoms. They described how they felt they needed to take more control of their lives in order to change their situations. However, they also acknowledged that they discovered that they had not prioritized their lives and routines around themselves. In fact, their families and work came first. If something was to change, they needed to
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care for themselves, move on and learn to live again. This pattern was also shown in other studies of women with FM.27,25,24,28,29 There is a growing amount of literature on the efficacy of CAT; nevertheless, more is needed to understand the therapies in order to build up evidence-based literature for their use.30 Unfortunately, the research activity in complementary medicine is lacking in funding, training and expertise in research methodologies, along with a lack of interest among experienced researchers and inadequate tools to measure outcomes in complementary medicine.31 Currently most research on the efficacy of CATs is focused on using quantitative methods, which strip important aspects of lived experience from such studies. Nurses are in a primary position to conduct research on reflexology, in that their holistic background is in tune with the philosophies behind reflexology. Before reflexology is to be used within hospital settings to benefit patients, more empirical research evidence is needed to support its use. 7. Conclusions Reflexology may help to decrease the experience of pain in patients with FM. The findings of this study demonstrate that the multiple case study analysis used gives reflexology research a new insights into the experience of FM. Therefore, an increased use of qualitative approaches in researching complementary and alternative therapies is recommended. By adding qualitative research methods to researching complementary therapies, an increased understanding of CATs can be greatly enhanced. The disadvantage of the multiple case study approach for this study was that it is focused only on six cases, thereby limiting the transferability of the findings to other populations. Health care providers help their patients to deal with their symptoms, such as pain and discomfort. In addition, they care about healing, alleviating health problems, and managing symptoms. Reflexology and other CATs may offer important tools to increase the healing mechanisms in their patients. Reflexology can be a prime tool to provide caring, presence showing compassion in combination with a feeling of doing something that may help a patient to become more whole and feel better. Acknowledgments The research reported here was supported by The Icelandic Centre for Research (Rannis). Icelandic Nurse’s Association, The Nursing Research Institute at the Faculty of Nursing and Minning Margretar. References 1. Wolfe F. Development of criteria for the diagnosis of fibrosistitis. American Journal of Medicine 1986;81:99–106. 2. Boissevain MD, McCain GA. Toward an integrated understanding of fibromyalgia syndrome. II. Psychological and phenomenological aspects. Pain 1991;45:239–48. 3. Bengtsson A, Henriksson KG. The muscle in fibromyalgia: a review of Swedish studies. Journal of Rheumatology 1989;16:144–9. 4. Dimmock S, Troughton PR, Bird HA. Factors predisposing to the resort of complementary therapies in patients with fibromyalgia. Clinical Rheumatology 1996;15:478–82. 5. Carette S, McCain GA, Bell DA, Fam AG. Evaluation of amitriptyline in primary fibrositis: a double-blind, placebo-controlled study. Arthritis Rheumatica 1986;29:655–9. 6. Burckhardt CS, Mannerkorpi K, Hedenberg L, Bjelle A. A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. Journal of Rheumatology 1994;21:714–20. 7. Haanen HC, Hoenderdos HT, van Romunde LK, Hop WC, Mallee C, Terwiel JP, et al. Controlled trial of hypnotherapy in the treatment of refractory fibromyalgia. Journal of Rheumatology 1991;18:72–5. 8. Sim J, Adams N. Systematic review of randomized controlled trials of nonpharmacological interventions for fibromyalgia. The Clinical Journal of Pain 2002;18(5):324–36.
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9. Nicassio PM, Schuman C, Kim J, Cordova A, Weisman MH. Psychosocial factors associated with complementary treatment use in fibromyalgia. Journal of Rheumatology 1997;24:2008–13. 10. Pioro-Boisset M, Esdaile JM, Fitzcharles MA. Alternative medicine use in fibromyalgia syndrome. Arthritis Care Research 1996;24:937–40. 11. Dougans I. The complete illustrated guide to reflexology. Boston: Element Books; 1999. 12. Tiran D. Reviewing theories and origins. In: Mackereth PA, Tiran D, editors. Clinical reflexology. Edinburgh: Churchill Livingstone; 2002. p. 5–15. 13. Gunnarsdottir TJ. Reflexology. In: Snyder M, Lindquist R, editors. Complementary & alternative therapies in nursing. New York: Springer Publishing Company; 2010. p. 307–20. 14. Ingham ED. Stories the feet can tell thru reflexology/stories the feet have told thru reflexology. Saint Petersburg, FL: Ingham Publishing; 1984. 15. Stephenson LN, Weinrich SP, Tavakoli AS. The effects of foot reflexology on anxiety and pain in patients with breast and lung cancer. Oncology Nursing Forum 2000;27(1):67–72. 16. Hodgson H. Does reflexology impact on cancer patients’ quality of life? Nursing Standard 2000;14(31):33–8. 17. Joyce M, Richardson R. Reflexology can help MS. International Journal of Alternative and Complementary Medicine 1997;July:10–2. 18. Launso¨ L, Brendstrup E, Arnberg S. An exploratory study of reflexological treatment for headache. Alternative Therapies in Health and Medicine 1999;5(3):57–65. 19. Siev-Ner I, Gamus D, Lerner-Geva L, Achiron A. Reflexology treatment relieves symptoms of multiple sclerosis: a randomized controlled study. Multiple Sclerosis 2003;9:356–61.
20. Mackereth PA, Booth K, Hillier VF, Caress A. Reflexology and progressive muscle relaxation training for people with multiple sclerosis: a crossover trial. Complementary Therapies in Clinical Practice 2009;15:14–21. 21. Wang M, Tsai P, Lee P, Chang W, Yang C. The efficacy of reflexology: a systematic review. Journal of Advanced Nursing 2008;62(5):512–20. 22. Gunnarsdottir TJ, Jonsdottir H. Does the experimental design capture the effects of complementary therapy? A pilot study using reflexology for patients undergoing coronary artery bypass graft surgery. Journal of Clinical Nursing 2007;16:777–85. 23. Stake RE. Multiple case study analysis. New York: Guilford Publications; 2006. 24. So¨derberg S, Norberg A. Metaphorical pain language among fibromyalgia patients. Scandinavian Journal of Caring Science 1995;9:55–9. 25. Schaefer KM. Health patterns of women with fibromyalgia. Journal of Advanced Nursing 1997;26(3):565–71. 26. Stephenson N, Dalton JA, Carlson J. The effect of foot reflexology on pain in patients with metastatic cancer. Applied Nursing Research 2003;16(4):284–6. 27. Schaefer KM. Struggling to maintain balance: a study of women living with fibromyalgia. Journal of Advanced Nursing 1995;21(1):95–102. 28. So¨derberg S, Lundman B, Norberg A. The meaning of fatigue and tiredness as narrated by women with fibromyalgia and healthy women. Journal of Clinical Nursing 2002;11:247–55. 29. Råheim M, Håland W. Lived experience of chronic pain and fibromyalgia: women’s stories from daily life. Qualitative Health Research 2006;16:741–61. 30. Snyder M, Lindquist R. Complementary & alternative therapies in nursing. 6th ed. New York: Springer Publishing Company; 2010. 31. House of Lords. Selected committee on science and technology. Complementary and alternative medicine. London: The Stationery Office; 2000.
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctnm
Effects of reflexology on fibromyalgia symptoms: A multiple case study Thora Jenny Gunnarsdottir a, *, c, Cynthia Peden-McAlpine b, d a b
Faculty of Nursing, University of Iceland, Reykjavik, Iceland University of Minnesota, School of Nursing, MN, USA
a b s t r a c t Keywords: Reflexology Fibromyalgia syndrome Multiple case study Nursing Symptom
Purpose: To explore the effects of reflexology on pain and other symptoms in women with fibromyalgia syndrome [FM]. Methods: Multiple case study method as developed by Stake was used to investigate the effects of reflexology on six cases of women with FM which were given ten sessions of weekly reflexology. Data were collected with observation, interviews and diary and then analyzed within cases and across cases. Results: Reflexology affected the symptom of pain in multiple areas such as head, neck and arms. Pain started to isolate and decrease. Conclusion: Reflexology may be helpful to decrease fibromyalgia symptoms. Qualitative research methods and individually tailored interventions are important when researching complementary and alternative therapies. Ó 2010 Elsevier Ltd. All rights reserved.
1. Introduction Fibromyalgia syndrome (FM) is a rheumatologic syndrome, manifested as a chronic disease with diffuse musculoskeletal aching and soreness, accompanied by poor sleep, fatigue, and morning stiffness.1 The etiology in FM is not fully known. Muscle abnormalities, sleep disturbances, and a biochemical unbalanced metabolism have all been considered as playing a part in FM.2 Fibromyalgia tends to be more common among women than men, with female prevalence ranging from 73% to 88%.2 The impact of this disease is severe for patients, both physically and economically and studies have found that 44% of patients with FM may be unable to perform household tasks without assistance.3 FM patients often feel disabled by fatigue and may not be able to hold a full-time job or perform everyday activities.3 Conventional medicine falls short in providing expected sustained relief from pain in patients with FM.4 No treatment interventions, whether pharmacological,5 lifestyle manipulations,6,7 or
* Corresponding author. Tel.: þ354 5254982; fax: þ354 5254963. E-mail addresses: [email protected] (T.J. Gunnarsdottir), [email protected] (C. Peden-McAlpine). c Thora J. Gunnarsdottir is assistant professor at the Faculty of Nursing at the University of Iceland. Her program of research is in complementary and alternative therapies in nursing practice. d Cynthia Peden-McAlpine is associate professor at the University of Minnesota, School of Nursing. Her program of research includes expertise in qualitative methodology, clinical judgment and reflective practice strategies and the inclusion of families in the end of live care. 1744-3881/$ – see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2010.01.006
nonpharmacological agents8 have been found to be universally successful in improving the symptoms of FM. Patients with FM have been reported to have explored complementary and alternative therapies (CAT).9 An assessment of the use and satisfaction with alternative medicine practices used by FM patients and a comparison of FM to other rheumatology patients were done in a study in Canada.10 The findings indicated that 73 (91%) of FM patients identified alternative medicine use, compared to 140 (63%) of control patients. Few rigorous studies have demonstrated the effects of reflexology as an effective treatment for chronic symptoms. 2. Background Reflexology is a specific pressure technique that works on precise reflex points of the feet, based on the premise that reflex areas on the feet correspond to all body parts. Because the feet represent a microcosm of the body, all organs, glands, and other body parts are laid out in a similar arrangement on the feet.11 The literature implies that reflexology is useful for achieving and maintaining health, enhancing wellbeing, and helpful for relieving the symptoms of illness and disease.12,13 Studies of reflexology have been reported to help to alleviate the effects of stress by inducing deep relaxation so one’s body can regain homeostasis,11,14 decrease anxiety in patients with breast and lung cancer,15 increase comfort and quality of life in patients with cancer16 and Multiple Sclerosis.17 It has also been shown to help migraine patients relief headache and reduce pain medication intake,18 and relieve symptoms of multiple sclerosis.17,19,20 The
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effect of reflexology on symptoms of fibromyalgia has not been reported in previous studies. A recent systematic review of the efficacy of reflexology states that there is no evidence for any specific effect of reflexology in any conditions except of urinary symptoms associated with multiple sclerosis.21 The authors did therefore not recommend routine provision of reflexology. However in a study of the effects of reflexology on patients undergoing coronary artery bypass graft surgery it is suggested that reflexology should be tailored to individual needs and research methods used that allow for capturing its holistic nature.22 3. Methods 3.1. Study design Given the questionable evidence base of the state of reflexology research and the need to allow for individually based treatments led the researchers to do a systematic and inductive study of reflexology, using a qualitative design; the multiple case study method as described by Robert Stake.23 In this study, each case consists of one participant suffering from Fibromyalgia Syndrome (FM) who undergoes 10 reflexology sessions. Each case was looked at individually and then the cases were collapsed together in order to make assertions about reflexology for FM patients. Each case to be studied has its own problems, and stories to tell but the main research interest is in the evaluation of multiple cases. The main research question focused on was: Do the participants experience changes of pain or other symptoms during multiple reflexology treatments in the study period? 3.1.1. Procedures and setting An MD who specializes in treating patients with FM recruited eligible participants, men or women, who were diagnosed with FM according to the American College of Rheumatology criteria (Table 1). Six women with FM took part in the study. The youngest one 27 years old, and the oldest 55 yr, with a mean age of 39 years. Four of them were married with children. They had all been recently diagnosed with FM, although some of them had been battling with symptoms for years. An average of four to ten cases is thought to be most appropriate for a multiple case study.23 The necessary steps to obtain permission and authorization through the Institutional Review Board (IRB) at the University of Minnesota, from Protection of Personal Data in Iceland, and from The National Bioethics Committee in Iceland were obtained. Written consent was also obtained from all participants involved in the study. The reflexology sessions took part in a reflexology clinic. One reflexologist administered all reflexology treatments in the study in order to reduce any possible inter-rater reliability issues. All of the areas in the feet were assessed and worked on during the first session. In the second session, a comprehensive assessment was done again on both feet, and each participant was asked specifically about his/her state in connection to the findings from the former session. These findings guided the second session; whatever was Table 1 Guidelines for inclusion/exclusion. 18 years or older Native speaking Diagnosed with FM Having both feet and all toes intact and free from wounds No use of other complementary or alternative therapies during study Has no other significant health problem unrelated to FM No use of sleep medications No use of sedative or sleeping medications Referred by MD specialist in FM
found to be imbalanced was worked on, depending on each participant. The 10 sessions proceeded in the following manner: a period of 45 min was estimated to be adequate time to perform reflexology on both feet; however, extra time was allowed for specific work on areas needing further care. At the end of each session, the participant relaxed for at least 10–15 min. 4. Data collection Data were collected trough three major sources; interviews, observation and diary. The purpose of the interviews was to serve as a resource for developing a richer and deeper understanding of how the women experienced the effects of reflexology on their symptom experience, specifically on pain. All interviews were conducted privately, tape-recorded and transcribed. The researcher was present in the field during all of the sessions, recording and making field notes of what was taking place. The participants filled out a symptom diary for 13 weeks. The diary started one week before the first reflexology session and the diary writing finished two weeks after the last reflexology session. During each day of the study the participants were to write down any specific notions of symptoms such as their reflections on the quality of their sleep, medication intake and any sensations of pain or any other aggravating symptoms or benefits. If they were experiencing pain, they were asked to mark all of the different sites of their pain on a diagram of a body and to evaluate the strength of the pain at each site using a Numerical Rating Scale (NRS). The zero point indicates ‘‘no pain at all’’ while 10 indicates ‘‘the worst pain imaginable.’’ The participants were asked to mark a score on the line corresponding to the amount of pain sensation they experienced. 4.1. Data analysis Data were analyzed both within case and cross cases.23 In the within case analysis all of the data for each case were reviewed, and a general description of the experience of reflexology on pain and symptoms was recorded. Each participant’s pain was mapped out to give a graphic format of how it was experienced during the study according to the diary. The main activity of a cross-case analysis consisted of reading the case reports as a whole, all of the original data, with special attention to the commonalities, uniqueness, confusions, contraindications and missing information between the cases regarding any salient issues. 5. Results 5.1. Within case analysis A very short description is given for each participant that focuses on the experience of pain as it was reflected during the study and a graph of pain experience of each participant is provided. The first participant Anna has been battling symptoms of pain with fatigue for over twenty years. She has difficulty describing her pain. Some days it is only light obtuse pain, but other days, it feels like a throbbing pain. Anna described several changes in pain that had occurred during the sessions. She actually felt worse during the first weeks of the study especially having bad headaches and neck pain during the first two weeks and she had to try hard to keep herself from taking medications which she didn’t want to do. In session five when the therapist was working to relief her headache, Anna noticed how the fog had disappeared from her head, making herself feel mentally ‘‘lighter.’’ She took deep breaths and then said, ‘‘The veil has gone from my head; it is just gone.’’ She could feel how it suddenly had gotten lighter and the heaviness over her head
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had disappeared. This heavy sensation did not return during the study period. The diagram of pain over the study period shows this well for Anna (Fig. 1). At the end of the study she reported less pain in her head, arms, hips and elbows. Additionally, the pain in her hip joints and in her fingers became much better and her perspiration had become much less than before. What did not change was the pain around the coccyx. Betsy described her pain as a throbbing-like sensation of being stabbed in several places by a knife, but also experienced stiffness and numbness, especially in the mornings. As evident in the diagram made from Betsy’s experience of pain during the study (Fig. 2) she first gets worse but then much better around week seven and eight. She describes how her stiffness subsides and she began to feel less irritation in her body. Therefore she decided to take on another job just because she was feeling so good. At the end of the study she was getting worse again, her stomach was in bad shape and the stiffness in her joints was back and she blamed her condition on the new job, additional stress, heavier workloads and wrong diet. Connie had chronic pain in her neck, and shoulders while experiencing numbness in her arms. In the last few months before the study, her condition has gotten increasingly worse. As shown in the diagram of the pain during the study it was evident that after the eighth session, things were dramatically turning better for her (Fig. 3). At the end of the study she was feeling much better than before the study. At about week nine she said, ‘‘This has been one of my best weeks.’’ The numbness was less and had almost disappeared from her arms; in addition, her headaches were less frequent. The fourth participant Donna was hit in a car accident and experienced whiplash; soon thereafter her body gradually became worse. In her own words, she said, ‘‘I remember that at first I was very tired and had no energy and was not able to get going. Then just very slowly, I started to stiffen up in one area after another and couldn’t move as easily. But this just happened very slowly after the accident over the period of a year. It started at the back of my neck, but then started to move down the body to my arms and down my shoulders and then to my chest area. Now it is also in my lower back.’’ For Donna, pain changed during the study. She acknowledged this in her diary ‘‘The first weeks were tough, so it was an uphill battle. Then around week seven, it started to go down again, and then I suddenly realized that I was feeling better, both physically and emotionally. There was less pain and better sleep and more energy than I had before I started [the study]. It just suddenly
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occurred to me. I was going over my diary and making sure that I had everything there, and then suddenly I noticed VOW!! And it kept on being that way. I mean, with having Fibromyalgia and all that, I would be happy if I could just be in this place and not go downhill again.’’ She also stated that during the study when she was overloaded with work and stress, she was in much better shape to deal with it and concentrate on it, despite being tired. The week between sessions eight and nine were the best for Donna in a long time (Fig. 4). Ella experienced pain in her back and at the back of head that bothers her everyday and frequently gets migraine headaches. She stated that her symptoms started to appear some fifteen years ago after the car accident. During the study it is evident in the graph from Ella that there is not much change in pain from the first to the last sessions (Fig. 5). Over the sessions, not much progress occurred; in fact, for the whole time Ella experienced the same pain in the same spots throughout the study. Sometimes there was also pain in her elbows. When asked about her migraine headaches, she suddenly realized that they had not been bothering her for over three months, which was a relatively long period of time. In fact, her headaches had not bothered her since starting her reflexology sessions. At the beginning of the study Ella took on a new job which became a more increased workload than expected. Although she did not express any changes during the study she comments on how despite her workload she felt better than expected. Fanny has a long story of pain and chronic fatigue. The pain is all over the body and she describes it as heavy burdensome sore and overwhelming in her head, shoulders, back and arms. In summary, the reflexology sessions did not do much for Fanny. After the study started, there were some changes and benefits that came and went quickly. She noticed some relief of the ‘‘helmet’’ on her head and some lightness in other areas. However, this relief never lasted long
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enough, and usually not throughout the day of the session. All activities during the day affected her wellbeing. If she felt better after a session, the benefits would disappear while she drove home because merely driving a car increased her pain. It was obvious that her condition was very severe and reflexology did not have much to offer to her. The reason for her graph being different is due to the aggressiveness of the pain which was constantly fluctuating each day (Fig. 6). 5.2. Cross-case analysis Although the women had different stories to tell, they all seemed to have suffered from an accident or shock, or some traumatic experience that they identified as a starting point of their FM. Pain was sensed the most prominent symptom the women sense as a part of FM. They described their pain starting in isolated areas, then traveling from one area to another. Some women remembered how the pain progressed by starting in one area in the body, then beginning to show up in other areas, until the entire body had somehow become affected. The pain was felt mostly in the joints and muscles, but was described as different from muscle soreness. Some painful areas responded to better to reflexology, such as headaches, pain in shoulders, arms and the neck, as evident by lessening pain strength or the pain disappearing. At specific sites, the pain remained in the joints, the fingers, or the coccyx, depending on each individual. However at most of those sites the level of pain decreased during the study. The pain is also described in the graphs of pain as drawn by the women in each case. The graphs were verified with their diaries to make sure that what they had reflected in writing was corroborated by the figure above. When examining the lines in the graphs, the subjects who showed decreased pain on the graph all started to get
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worse first. For most of them, this worsening was immediately after the first session, while for others, it was an ongoing experience, up to the seventh session. They described their condition as either being worse in pain or feeling worse in their body. There were times when some considered withdrawing from the study but decided to hang on and see what happened. It is interesting to see that at approximately the sixth to eighth weeks, four of the six women started to show dramatic changes in their wellbeing and felt much better rather suddenly during the eighth and ninth weeks. Sleep disturbance is a symptom frequently seen in FM. Therefore, a specific section in the diary was used to record the participants’ sleep patterns for each day. They described their sleep as not being enough, as waking up without feeling adequately rested and as awakening with stiffness and pain. At the end of the study, the patterns of sleep did not change much for any of the participants. Their sleep rhythms were similar throughout the study, and they interpreted these rhythms as ‘‘not good enough.’’ The findings in each case indicated that the quality of sleep depended more on what was happening in their lives rather than on the disease itself. The most significant factors affecting their sleep were disturbances by children, their work schedule, stress or keeping themselves occupied instead of going to bed. Some other health problems or FM symptoms responded to the reflexology. This finding was evident for migraine headaches, edema, and fecal elimination problems. Migraine headaches, which were a common problem for two of the participants, did not happen during the study. Also, if a women had the tendency to get edema in their legs or other areas, then this commonly decreased during the study period. However, these effects did not last long after the study period; moreover, their edema often fluctuated along with the women’s menstrual cycles, becoming worse the week before menstruation. Fecal elimination became more normal for some, and they described their stools becoming looser and more frequent. Events going on in their lives definitely affected the way they felt during the study. All but one of the participants was working outside the home, and their work affected their FM symptoms. However, it was interesting that several of the women reported that they were able to take on more responsibilities or were able to increase their workload during the study period. Five of the women talked about how they did not feel as tired as they had before the study started; indeed, they did not feel as ‘‘loaded’’ with their symptoms, even though their workloads or stressors had increased. Three participants (Anna, Connie and Donna) detected benefits after the first few sessions, which seemed to increase their control over their FM symptoms, enabling them to cope better. That sentiment lasted throughout the study for these three participants. Two of the women (Betsy and Ella) began new jobs during the study period. At the end of the study they alluded to how that workload affected their symptoms and wellbeing and increased their stress seriously. Betsy showed improved wellbeing at first, but
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her condition worsened as her workload and stress increased. Ella’s status did not change over the study period, showing also that she did not get any worse. She also described how frustrating it was not to find any benefits from the reflexology and lost interest in what was going on in the sessions over time. For the sixth participant (Fanny), it was obvious right at the beginning that her symptoms were very serious, and her entire days had to be scheduled around her pain. It was difficult for her to add the sessions to her schedule, as she already had other appointments during the week. Although she could relax during most of the sessions, the reflexology effects had completely disappeared on the way home, just by stress from driving or because the weather was cold. 6. Discussion The study findings demonstrated that pain was the most prevalent symptom and was evident by how the women recorded their pain each day in their diaries and how they were feeling at different sites in their bodies during the day. The pain was sensed as more severe than muscle soreness, although it was mostly sensed in the muscles and joints. The women described the pain as all over, sore, numb, aching and hurting; they narrated how it was always present, constant and wandering from one location to another, similar to previously documented fibromyalgia pain24 and as both mental and physical.25 The pain changed during the study and started to become more isolated and decreased in severity in four out of six cases. The areas that responded best were the head, shoulders, neck and arms. This phenomenon was most evident after the seventh or eighth sessions, indicating that several sessions of reflexology are needed in order to show evidence of lasting benefits. The findings demonstrated that the participants experienced some pain relief that increased their wellbeing. Pain at specific sites decreased, especially headaches and migraine headaches. This result reflects findings from two other studies of reflexology, in which patients described less pain following reflexology.18,26 In general, pain in some areas did not change during this study; for example, pain in joints. It may have been that they had become too chronic or needed more reflexology sessions in order to have any effect. Benefits of reflexology for other symptoms such as edema and fecal elimination have been reported before.17 Looking at the figures of pain for each participant it is interesting that before the women got better they got worse. This may be a factor in healing and needs to be analyzed further. The findings supported the theoretical framework behind reflexology, which aims to heal and to restore balance and wholeness. When the women felt the process of recovery and repair take place, they felt more whole and gained a better sense of coherence. In four cases, the pain decreased in specific places. These phenomena took place as the women started showing dramatic changes between the sixth to eighth sessions. In the study by Launso¨ et al.,18 in depth interviews were conducted with 10 of the participants. The analysis of the interviews demonstrated that patients who considered themselves cured based this on their involvement with reflexology and the fact that they did a lot of thinking about their health and their understanding of the headache changed. They recognized the headache as part of the body and therefore related to a mind–body connection. The women were all eager to try reflexology, as they had previously been trying other CATs to relief symptoms. They described how they felt they needed to take more control of their lives in order to change their situations. However, they also acknowledged that they discovered that they had not prioritized their lives and routines around themselves. In fact, their families and work came first. If something was to change, they needed to
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care for themselves, move on and learn to live again. This pattern was also shown in other studies of women with FM.27,25,24,28,29 There is a growing amount of literature on the efficacy of CAT; nevertheless, more is needed to understand the therapies in order to build up evidence-based literature for their use.30 Unfortunately, the research activity in complementary medicine is lacking in funding, training and expertise in research methodologies, along with a lack of interest among experienced researchers and inadequate tools to measure outcomes in complementary medicine.31 Currently most research on the efficacy of CATs is focused on using quantitative methods, which strip important aspects of lived experience from such studies. Nurses are in a primary position to conduct research on reflexology, in that their holistic background is in tune with the philosophies behind reflexology. Before reflexology is to be used within hospital settings to benefit patients, more empirical research evidence is needed to support its use. 7. Conclusions Reflexology may help to decrease the experience of pain in patients with FM. The findings of this study demonstrate that the multiple case study analysis used gives reflexology research a new insights into the experience of FM. Therefore, an increased use of qualitative approaches in researching complementary and alternative therapies is recommended. By adding qualitative research methods to researching complementary therapies, an increased understanding of CATs can be greatly enhanced. The disadvantage of the multiple case study approach for this study was that it is focused only on six cases, thereby limiting the transferability of the findings to other populations. Health care providers help their patients to deal with their symptoms, such as pain and discomfort. In addition, they care about healing, alleviating health problems, and managing symptoms. Reflexology and other CATs may offer important tools to increase the healing mechanisms in their patients. Reflexology can be a prime tool to provide caring, presence showing compassion in combination with a feeling of doing something that may help a patient to become more whole and feel better. Acknowledgments The research reported here was supported by The Icelandic Centre for Research (Rannis). Icelandic Nurse’s Association, The Nursing Research Institute at the Faculty of Nursing and Minning Margretar. References 1. Wolfe F. Development of criteria for the diagnosis of fibrosistitis. American Journal of Medicine 1986;81:99–106. 2. Boissevain MD, McCain GA. Toward an integrated understanding of fibromyalgia syndrome. II. Psychological and phenomenological aspects. Pain 1991;45:239–48. 3. Bengtsson A, Henriksson KG. The muscle in fibromyalgia: a review of Swedish studies. Journal of Rheumatology 1989;16:144–9. 4. Dimmock S, Troughton PR, Bird HA. Factors predisposing to the resort of complementary therapies in patients with fibromyalgia. Clinical Rheumatology 1996;15:478–82. 5. Carette S, McCain GA, Bell DA, Fam AG. Evaluation of amitriptyline in primary fibrositis: a double-blind, placebo-controlled study. Arthritis Rheumatica 1986;29:655–9. 6. Burckhardt CS, Mannerkorpi K, Hedenberg L, Bjelle A. A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. Journal of Rheumatology 1994;21:714–20. 7. Haanen HC, Hoenderdos HT, van Romunde LK, Hop WC, Mallee C, Terwiel JP, et al. Controlled trial of hypnotherapy in the treatment of refractory fibromyalgia. Journal of Rheumatology 1991;18:72–5. 8. Sim J, Adams N. Systematic review of randomized controlled trials of nonpharmacological interventions for fibromyalgia. The Clinical Journal of Pain 2002;18(5):324–36.
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9. Nicassio PM, Schuman C, Kim J, Cordova A, Weisman MH. Psychosocial factors associated with complementary treatment use in fibromyalgia. Journal of Rheumatology 1997;24:2008–13. 10. Pioro-Boisset M, Esdaile JM, Fitzcharles MA. Alternative medicine use in fibromyalgia syndrome. Arthritis Care Research 1996;24:937–40. 11. Dougans I. The complete illustrated guide to reflexology. Boston: Element Books; 1999. 12. Tiran D. Reviewing theories and origins. In: Mackereth PA, Tiran D, editors. Clinical reflexology. Edinburgh: Churchill Livingstone; 2002. p. 5–15. 13. Gunnarsdottir TJ. Reflexology. In: Snyder M, Lindquist R, editors. Complementary & alternative therapies in nursing. New York: Springer Publishing Company; 2010. p. 307–20. 14. Ingham ED. Stories the feet can tell thru reflexology/stories the feet have told thru reflexology. Saint Petersburg, FL: Ingham Publishing; 1984. 15. Stephenson LN, Weinrich SP, Tavakoli AS. The effects of foot reflexology on anxiety and pain in patients with breast and lung cancer. Oncology Nursing Forum 2000;27(1):67–72. 16. Hodgson H. Does reflexology impact on cancer patients’ quality of life? Nursing Standard 2000;14(31):33–8. 17. Joyce M, Richardson R. Reflexology can help MS. International Journal of Alternative and Complementary Medicine 1997;July:10–2. 18. Launso¨ L, Brendstrup E, Arnberg S. An exploratory study of reflexological treatment for headache. Alternative Therapies in Health and Medicine 1999;5(3):57–65. 19. Siev-Ner I, Gamus D, Lerner-Geva L, Achiron A. Reflexology treatment relieves symptoms of multiple sclerosis: a randomized controlled study. Multiple Sclerosis 2003;9:356–61.
20. Mackereth PA, Booth K, Hillier VF, Caress A. Reflexology and progressive muscle relaxation training for people with multiple sclerosis: a crossover trial. Complementary Therapies in Clinical Practice 2009;15:14–21. 21. Wang M, Tsai P, Lee P, Chang W, Yang C. The efficacy of reflexology: a systematic review. Journal of Advanced Nursing 2008;62(5):512–20. 22. Gunnarsdottir TJ, Jonsdottir H. Does the experimental design capture the effects of complementary therapy? A pilot study using reflexology for patients undergoing coronary artery bypass graft surgery. Journal of Clinical Nursing 2007;16:777–85. 23. Stake RE. Multiple case study analysis. New York: Guilford Publications; 2006. 24. So¨derberg S, Norberg A. Metaphorical pain language among fibromyalgia patients. Scandinavian Journal of Caring Science 1995;9:55–9. 25. Schaefer KM. Health patterns of women with fibromyalgia. Journal of Advanced Nursing 1997;26(3):565–71. 26. Stephenson N, Dalton JA, Carlson J. The effect of foot reflexology on pain in patients with metastatic cancer. Applied Nursing Research 2003;16(4):284–6. 27. Schaefer KM. Struggling to maintain balance: a study of women living with fibromyalgia. Journal of Advanced Nursing 1995;21(1):95–102. 28. So¨derberg S, Lundman B, Norberg A. The meaning of fatigue and tiredness as narrated by women with fibromyalgia and healthy women. Journal of Clinical Nursing 2002;11:247–55. 29. Råheim M, Håland W. Lived experience of chronic pain and fibromyalgia: women’s stories from daily life. Qualitative Health Research 2006;16:741–61. 30. Snyder M, Lindquist R. Complementary & alternative therapies in nursing. 6th ed. New York: Springer Publishing Company; 2010. 31. House of Lords. Selected committee on science and technology. Complementary and alternative medicine. London: The Stationery Office; 2000.