© 2011 Korean Society of Nursing Science www.kan.or.kr | ISSN 2005-3673
Effects of Foot Reflexology on Fatigue, Sleep and Pain:
A Systematic Review and Meta-analysis
Lee, Jeongsoon1·Han, Misook2·Chung, Younghae3·Kim, Jinsun4·Choi, Jungsook5
1Full-time Lecturer, Department of Nursing, Christian College of Nursing, Gwangju
2Full-time Lecturer, Department of Nursing, Songwon University, Gwangju
3Professor, Department of Nursing, Dongshin University, Naju
4Associate Professor, Department of Nursing, Chosun University, Gwangju
5Head Nurse, Naju National Hospital, Naju, Korea
J Korean Acad Nurs Vol.41 No.6, 821-833
http://dx.doi.org/10.4040/jkan.2011.41.6.821J Korean Acad Nurs Vol.41 No.6 December 2011?
Purpose: The purpose of this study was to evaluate the effectiveness of foot reflexology on fatigue, sleep and pain. Meth-
ods: A systematic review and meta-analysis were conducted. Electronic database and manual searches were conducted on
all published studies reporting the effects of foot reflexology on fatigue, sleep, and pain. Forty four studies were eligible in-
cluding 15 studies associated with fatigue, 18 with sleep, and 11 with pain. The effects of foot reflexology were analyzed us-
ing Comprehensive Meta-Analysis Version 2.0. The homogeneity and the fail-safe N were calculated. Moreover, a funnel plot
was used to assess publication bias. Results: The effects on fatigue, sleep, and pain were not homogeneous and ranged
from 0.63 to 5.29, 0.01 to 3.22, and 0.43 to 2.67, respectively. The weighted averages for fatigue, sleep, and pain were 1.43,
1.19, and 1.35, respectively. No publication bias was detected as evaluated by fail-safe N. Foot reflexology had a larger effect
on fatigue and sleep and a smaller effect on pain. Conclusion: This meta-analysis indicates that foot reflexology is a useful
nursing intervention to relieve fatigue and to promote sleep. Further studies are needed to evaluate the effects of foot reflexol-
ogy on outcome variables other than fatigue, sleep and pain.
Key words: Systematic review, Foot reflexology, Fatigue, Sleep, Pain
Address reprint requests to: Han, Misook
Department of Nursing, Songwon University, 365 Songha-dong, Nam-gu, Gwangju 503-742, Korea
Tel: +82-62-360-5945 Fax: +82-62-360-5944 E-mail: firstname.lastname@example.org
Received: May 31, 2011 Revised: June 15, 2011 Accepted: December 19, 2011
Alternative medicine is used to improve the symptoms of diseases
and pain with the healing power of nature and to reinforce the im-
mune system and recuperative power of the body. In other words, al-
ternative medicine may be used to observe and harmonize physical,
mental, social, and environmental aspects in totality in patients (Oh,
1994). In recent years, the popularity of alternative medicine has
grown due to the increasing popularity of holistic approaches to
health that emphasize the integration of body, mind, and spirit along
with physical symptoms in improving health care and well-being (Im
& Nam, 2005). Therefore, patients with chronic diseases that are not
completely healed by modern medicine are increasingly using com-
plementary and alternative medicine in the process of seeking other
treatments (Lee & Park, 1999).
Because of the growing popularity of complementary and alterna-
tive medicine as holistic approaches to health, many reports have
demonstrated that medical services utilizing both western and tradi-
tional medical practices have positive effects on the psychological sta-
bility of subjects (Cho, 1999). Meridian massages can be made more
J Korean Acad Nurs Vol.41 No.6 December 2011
systematic by combining the meridian concept of oriental medicine
with massage and has been applied to treat a variety of diseases be-
yond the scope of general massage (Lee, 1992). Consequently, many
medical practitioners have begun to adopt more positive attitudes to-
ward alternative medicine (Eisenberg, Kessler, & Foster, 1993).
Recently, nursing interventions involving various aspects of alter-
native are better understood and accepted in practice. Many studies
have been conducted to verify its effects and assess its role as an inter-
vention (Norred, Zamudio, & Palmer, 2000). It is reported that 32%-
41% of chronic patients in Western Europe and 60%-75% of patients
in Korea use alternative medicine (Choi, Jeong, & Choi, 1998; Foltz et
Foot reflexology therapy has a long history; it appeared in an an-
cient tomb mural in Egypt around 2330 B.C. and was organized by
William Hope Fitzgerald, an American doctor, in 1917 (Kim, 1999).
Because it is free from side effects, easy to learn and perform, and re-
quires only a little knowledge on meridian, foot reflexology has be-
come popular in the general public (Yang, 2005). It is well acknowl-
edged that foot reflexology therapy effectively facilitates blood and
lymph circulation which accelerate the excretion of waste, soften and
stabilize the movement of muscle, joints, and tendons, reinforce mus-
cle strength, and promote relaxation (Kim, 2001).
Meta-analysis is a statistical method commonly used to objectively
generalize parameters and to derive systematic information from
many studies on same topic studied over a long periods of time. It has
the advantage of obtaining reliable and useful information and of
suggesting evidence by systematic analysis and national interpretion
(Song, 1998). The meta-analysis has been applied to many nursing
fields for it is very useful in summarizing the effects of nursing inter-
ventions (Kim, 2009; Kim, 2011; Min, 2011).
Since systematic consideration for meta-analysis requires rigorous
methodological protocols, possible deviations and biases across all
phases must be considered to obtain reliable and accurate conclu-
sions (Scanlin, 2006). Conclusions drawn from such rigorous process
provide an excellent evidence for clinical practice (Evans, 2001).
A few meta-analyses evaluating the effects of foot reflexology have
been conducted (Kim, 2009; Kim, 2011; Min, 2011). Kim (2009) per-
formed a meta-analysis to evaluate the effects of foot reflexology on
14 outcome variables including fatigue, sleep, and pain. A meta-anal-
ysis was conducted to evaluate the effects of foot reflexology on can-
cer patients (Kim, 2011), and another meta-analysis was conducted to
evaluate the effects on pain among cancer patients (Min, 2011). How-
ever, Kim (2009)’s study did not perform a systematic review or a
process for assessing the methodological quality of studies included
in the analysis.
The purpose of this study was to systematically review the effects
of foot reflexology on fatigue, sleep, and pain. The specific objectives
of this study were a) to analyze the effects of foot reflexology on fa-
tigue, sleep, and pain and b) to explore the differences due to various
characteristics of the subjects and the intervention. The results of this
study may provide useful evidence for developing an efficient model
of a foot reflexology program.
1. Research design
This study is a systematic review and meta-analysis of intervention
studies to evaluate the effects of foot reflexology on fatigue, sleep, and
pain. In this study, foot reflexology is an application of pressure to
specific points on the foot. It consists of 3 phases including a relax-
ation phase, a massage phase, and a finishing phase (Choi, 2002).
2. Inclusion and exclusion criteria for consideration of
studies for review
Studies satisfying the following criteria were included for the anal-
ysis: a) an intervention study utilizing foot reflexology; b) a random-
ized controlled trial (RCT) or nonequivalent control group pretest-
posttest study with a no intervention group as a control; c) a study
with homogeneity of the baseline characteristics between the experi-
mental and control groups; d) a study examining the effects of foot
reflexology on fatigue, sleep, or pain; e) a study with the mean and
standard deviations, the sample size of experimental and control
groups, or t-values to calculate effects; and f) a study considered to be
appropriate for meta-analysis evaluated by using a patient, interven-
tion, comparison and outcome (PICO) chart and by an evaluation
checklist for methodological quality (Higgins & Green, 2008). If an
article was published from a thesis or dissertation, the thesis or dis-
sertation was selected over published articles to prevent duplication
and to reduce publication bias.
J Korean Acad Nurs Vol.41 No.6 December 2011
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