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The Effects of Aromatherapy Massage and Reflexology on Pain and Fatigue in Patients with Rheumatoid Arthritis: A Randomized Controlled Trial

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Nonpharmacologic interventions for symptom management in patients with rheumatoid arthritis are underinvestigated. Limited data suggest that aromatherapy massage and reflexology may help to reduce pain and fatigue in patients with rheumatoid arthritis. The aim of this study was to examine and compare the effects of aromatherapy massage and reflexology on pain and fatigue in patients with rheumatoid arthritis. The study sample was randomly assigned to either an aromatherapy massage (n = 17), reflexology (n = 17) or the control group (n = 17). Aromatherapy massage was applied to both knees of subjects in the first intervention group for 30 minutes. Reflexology was administered to both feet of subjects in the second intervention group for 40 minutes during weekly home visits. Control group subjects received no intervention. Fifty-one subjects with rheumatoid arthritis were recruited from a university hospital rheumatology clinic in Turkey between July 2014 and January 2015 for this randomized controlled trial. Data were collected by personal information form, DAS28 index, Visual Analog Scale and Fatigue Severity Scale. Pain and fatigue scores were measured at baseline and within an hour after each intervention for 6 weeks. Pain and fatigue scores significantly decreased in the aromatherapy massage and reflexology groups compared with the control group (p < .05). The reflexology intervention started to decrease mean pain and fatigue scores earlier than aromatherapy massage (week 1 vs week 2 for pain, week 1 vs week 4 for fatigue) (p < .05). Aromatherapy massage and reflexology are simple and effective nonpharmacologic nursing interventions that can be used to help manage pain and fatigue in patients with rheumatoid arthritis.
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From the Department of Internal
Medicine Nursing, Hacettepe
University Faculty of Nursing,
Ankara, Turkey.
Address correspondence to Zehra Gok
Metin, PhD, RN, Research Assistant,
Department of Internal Medicine
Nursing, Hacettepe University Faculty
of Nursing, Ankara 06100, Turkey.
E-mail: zehragok85@hotmail.com
Received August 31, 2015;
Revised January 29, 2016;
Accepted January 30, 2016.
Funding: None.
Conflicts of interest: None.
1524-9042/$36.00
Ó2016 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2016.01.004
The Effects of
Aromatherapy Massage
and Reflexology on Pain
and Fatigue in Patients
with Rheumatoid
Arthritis: A Randomized
Controlled Trial
---Zehra Gok Metin, Research Assistant, PhD, RN
and Leyla Ozdemir, Associate Professor, PhD, RN
-ABSTRACT:
Nonpharmacologic interventions for symptom management in patients
with rheumatoid arthritis are underinvestigated. Limited data suggest
that aromatherapy massage and reflexology may help to reduce pain
and fatigue in patients with rheumatoid arthritis. The aim of this study
was to examine and compare the effects of aromatherapy massage and
reflexology on pain and fatigue in patients with rheumatoid arthritis.
The study sample was randomly assigned to either an aromatherapy
massage (n ¼17), reflexology (n ¼17) or the control group (n ¼17).
Aromatherapymassage was applied to both knees of subjects in the first
intervention group for 30 minutes. Reflexology was administered to
both feet of subjects in the second intervention group for 40 minutes
during weekly home visits. Control group subjects received no inter-
vention. Fifty-one subjects with rheumatoid arthritis were recruited
from a university hospital rheumatology clinic in Turkey between July
2014 and January 2015 for this randomized controlled trial. Data were
collected by personal information form, DAS28 index, Visual Analog
Scale and Fatigue Severity Scale. Pain and fatigue scores were measured
at baseline and within an hour after each intervention for 6 weeks. Pain
and fatigue scores significantly decreased in the aromatherapy massage
and reflexology groups compared with the control group (p<.05). The
reflexology intervention started to decrease mean pain and fatigue
scores earlier than aromatherapy massage (week 1 vs week 2 for pain,
week 1 vs week 4 for fatigue) (p<.05). Aromatherapy massage and
reflexology are simple and effective nonpharmacologic nursing inter-
ventions that can be used to help manage pain and fatigue in patients
with rheumatoid arthritis.
Ó2016 by the American Society for Pain Management Nursing
Pain Management Nursing, Vol 17, No 2 (April), 2016: pp 140-149
Original Article
BACKGROUND
Pain and fatigue related to rheumatoid arthritis (RA)
often decrease patients’ independence and may limit
activities of daily living, which can negatively impact
patients’ quality of life (Edwards, Bingham, Bathon,
& Haythornthwaite, 2006; Hewlett, Nicklin, &
Treharne, 2008; Pollard, Choy, Gonzalez, Khoshaba,
& Scott, 2006). Despite the high prevalence of RA-
related pain and fatigue, there are no curative treat-
ments (Cornell, 2007). Conventional treatments for
RA include pharmacologic treatments such as nonste-
roidal anti-inflammatory drugs (NSAIDs), corticoste-
roids, disease-modifying antirheumatic drugs
(DMARD), and biologic drugs. However, these treat-
ments have common and harmful side effects such as
liver and kidney toxicity, nausea, vomiting, loss of
appetite, anemia, and ocular or systemic infections
(Demirel & Kirnap, 2010). Additionally, these treat-
ments do not lead to a complete cure of the disease
or its symptoms.
Nonpharmacologic interventions have also been
employed to manage symptoms and improve func-
tional status (Kohara et al., 2004;
Ozdemir, Ovayolu, &
Ovayolu, 2013; Wang, Tsai, Lee, Chang, & Yang, 2008).
Nonpharmacologic interventions include physical ther-
apy and rehabilitation; exercises; nutrition; peripheral
techniques such as aromatherapy, massage, and refle-
xology; cognitive behavioral therapies; and acupun-
cture (Cramp et al., 2013; Hewlett et al., 2011; Wang
et al., 2008).
Aromatherapy is one of the complementary ther-
apy modalities widely used around the world to
manage chronic disease symptoms (Buckle, 1999;
Ernst, 2004; Kim, Nam, & Paik, 2005; Steflitsch &
Steflitsch, 2008). Aromatherapy is defined as the use
of essential oils extracted from plants to produce
physiologic or pharmacologic effects through the
sense of smell or absorption through the skin
(Steflitsch & Steflitsch, 2008). Essential oils have
been used for their antiseptic, antibacterial, analgesic,
anti-inflammatory, antispasmolytic, antitoxic, immune-
stimulatory, and relaxing effects for management of the
symptoms of cancer, respiratory diseases, migraine, hy-
pertension, arthritis, and muscle-related pain (Bas¸aran,
2009; Steflitsch & Steflitsch, 2008; Yip & Tam, 2008).
Essential oils have also been used with massage
because of their quick absorption into the skin. Aroma-
therapy and massage have been used in juvenile RA, fi-
bromyalgia, and chronic fatigue syndrome to relieve
pain, fatigue, morning stiffness, and anxiety (Ernst,
2004; Field, Diego, Hernandez-Reif, & Shea, 2007;
Field et al., 1997; Kim et al., 2005). Increased
physical and mental well-being have also been noted
(Brownfield, 1998; Ovayolu & Ovayolu, 2013). In a
quasi-experimental study, Kim et al. (2005) found
that aromatherapy massage significantly decreased
pain scores for patients with RA. In another quasi-
experimental study, Han et al. (2010) found that aroma-
therapy massage reduced pain scores and painful
inflamed joints in patients with RA.
Reflexology is another complementary therapy
modality with potential beneficial effects in RA. Reflex-
ology uses specific hand and finger techniques to apply
pressure to individual body parts and organs at specific
reflex points on the hands and feet to stimulate endo-
crine glands (Wang et al., 2008). Reflexology has
been found to decrease migraine, neck and arm, and
low back and muscle-related pain and to improve mus-
cle strength and tone (Gunnarsdottir & Peden-
McAlpine, 2010; Poole, Glenn, & Murphy, 2007;
Quinn, Hughes, & Baxter, 2008; Siev-Ner, Gamus,
Lerner-Geva, & Achiron, 2003). A case study reported
that reflexology significantly decreased pain scores
after six 1-hour reflexology session (Khan, Otter, &
Springett, 2006). Another study found that 45-minute
reflexology interventions over 6 weeks significantly
lessened fatigue in RA patients (Khan, Otter, &
Springett, 2006; Otter et al., 2010).
However, few of the previously mentioned studies
tested the effects of aromatherapy massage and reflex-
ology on RA-related pain and fatigue. The authors
could find no research comparing these modalities.
The aim of this randomized controlled trial was to
compare the effects of aromatherapy massage and
reflexology on pain and fatigue in patients with RA.
We hypothesized that aromatherapy massage and
reflexology interventions would decrease pain and fa-
tigue scores in subjects with RA.
METHODS
Ethical Considerations
This study was approved by the Ethical Commission of
Turgut Ozal University, Ankara. The aim and the
method of the study were explained to the subjects,
and informed consent was obtained from each of the
subjects. Study subjects were informed that if they
did not want to continue, they could withdraw from
the study without stating a reason.
Design and Sample
This was a randomized controlled trial comparing the
effects of aromatherapy massage, reflexology, and no
intervention on pain and fatigue levels in subjects
with RA. Data were collected between July 2014 and
January 2015. A convenience sample of 54 adults
141Aromatherapy Massage and Reflexology in Rheumatoid Arthritis
with RA was recruited from a rheumatology clinic of a
university hospital located in a large city in Turkey. All
subjects suffered from pain and fatigue symptoms. To
be included in the study, subjects must have been
18 years or older, diagnosed with RA for at least
1 year, had a Visual Analog Scale (VAS) score of $4
points and a Fatigue Severity Scale (FSS) score of $4
points, not currently using biological drug therapy,
and not currently receiving physiotherapy or using
any complementary therapy modalities. Subjects with
knee and foot wounds or surgery, cancer, osteoar-
thritis, essential oil allergies, and blood coagulation dis-
orders such as hemophilia were excluded from the
study. In addition, those who were pregnant, anemic,
or who had a Disease Activity Score (DAS28) >5.1
were also excluded from the study.
The software package G-power (Faul, Erdfelder,
Buchner, & Lang, 2009) was used to conduct an apriori
power analysis to calculate the number of subjects
required. Fifty-one subjects (17 subjects in each study
group) were required to detect an effect size of 0.3
at 80% power. The alpha level used to define signifi-
cance was 0.05.
Figure 1 presents a flow diagram of subject selec-
tion and progress through the study. Fifty-four subjects
met the inclusion criteria and providedconsent. Subjects
Assessed for eligibility (n = 90)
Excluded (n = 36)
Not meeting inclusion criteria
(n = 30)
Declined to participate (n = 6)
Other reasons (n = 0)
Analysed (n = 17)
Excluded from analysis (n = 0)
Lost to follow-up (n = 2)
1 Biological therapy
1 Withdrew
Allocated to aromatherapy
massage (n = 19)
Lost to follow-up (n = 1)
1 Moved
Allocated to reflexology (n = 18)
Analysed (n = 17)
Excluded from analysis (n = 0)
Allocated to control (n = 17)
Lost to follow-up (n = 0)
Analysed (n = 17)
Excluded from analysis (n =0 )
Allocation
Follow-Up
Analysis
FIGURE 1. -Flow diagram of subject progress through the phases of randomized trial.
142 Gok Metin and Ozdemir
were stratified by disease duration, VAS score, FSS score,
DAS28 score, and type of RA treatment (DMARD or
DMARD plus steroids). Next, subjects were assigned to
either the controlgroup (n ¼17) or experimental groups
that received aromatherapy massage (n ¼19) or reflex-
ology (n ¼18) interventions by using a random number
table. During the intervention, three subjects (two from
the aromatherapy massage group and one in the reflex-
ology group) were lost to attrition.
Data Collection
Baseline data were obtained by face-to-face interviews
with the subjects in the rheumatology clinic. In these
interviews demographic information as well as
DAS28, VAS, and FSS scores were obtained. Demo-
graphic information included the subject’s age, sex,
educational level, employment, smoking status, fre-
quency of exercise, health history data, treatment
period, treatment type, and use of complementary
therapies (Dirac¸o
glu, 2007; Edwards et al., 2006;
Helmick et al., 2008).
All study subjects’ physical examinations and
DAS28 score calculations were carried out by the
same rheumatologist. The principal investigator (PI) in-
terviewed subjects face-to-face after their physical
examinations and obtained demographic information,
VAS, and FSS scores. All study individuals were then in-
structed on how to rate their own VAS and FSS scores.
For the control group, the PI made weekly calls to
obtain subjects’ VAS and FSS scores during the study
period. For the individuals in the experimental groups,
the PI made weekly home visits to deliver aroma-
therapy massage or reflexology interventions, after
which subjects were asked to complete the VAS and
FSS scales within an hour following each intervention.
Instruments. DAS28 has four components measuring
tender-joint count, swollen-joint count, erythrocyte
sedimentation rate (ESR), and self-reported general
health. The 28 tender joint count (28TJC) and 28
swollen joint count (28SJC) both have a range of 0–
28. ESR range is 0–150; the general health (GH) range
is 0–100. DAS28 is a continuous index with a range of
0–9.4. The level of RA disease activity is classified as
low (DAS28 #3.2), moderate (DAS28 3.2 to #5.1),
or high (DAS28 >5.1). A DAS28 <2.6 corresponds
to remission status according to the American Rheuma-
tism Association (ARA) criteria (Fransen, Stucki, & van
Riel, 2003).
VAS for pain consists of a 10-cm horizontal scale
with the descriptor of no pain on the left and worst
TABLE 1.
Active Substances in Essential Oils and Their Effects
Essential Oil Active Substances (%) Effects on the Body
Juniperus officinalis a-Pinene (38.99) Analgesic
Sabinen (10.75) Antiviral
Mycren (13.39) Antioxidant
Limonene þb-Phelleandrene (4.05) Antitoxic
Terpinen-4-ol (3.92) Sedative
d-Germacren (3.66)
Lavendula augustifolia c-b-ocimen þlimonen (3.69) Anti-inflammatory
Linalool (30.51) Analgesic
Linalyacetat (36.62) Antiseptic
Lavandula asetat (2.90) Sedative
t-b-ocimen (3.03) Circulation-stimulating
1,8 Cineol (0.55) Cell regenerating
Terpinen-4-ol (2.91)
Cananga odarata Linalool þmethylbenzoat (7.54) Antiseptic
Geranylacetate (7.75) Muscle relaxant
b-Caryophellen (11.16) Cell regenerating
Germacren-D (19.16) Anti-neuralgic
t-t-a-Farnesen (10.45) Antidepressant
d-Cadinen (3.37) Analgesic
Benzyl benzoate (6.52)
Rosmarinus officinalis a-Pinen (11.32) Antiviral
Limonene (2.51) Antibacterial
1,8 cineol (47.18) Anti-inflammatory
Linalool (0.93) Antioxidant
Kampher (11.46)
b-Caryophylen (2.86)
143Aromatherapy Massage and Reflexology in Rheumatoid Arthritis
possible pain on the right (Eti Aslan, 2002; Scott &
Huskisson, 1979). Subjects were asked to place a
mark on the line at a point that corresponded to the
level of pain intensity they were currently feeling. To
provide group homogeneity, subjects were divided
into two subgroups: mild to moderate (4–6) and
severe (7–10) pain intensity.
The Fatigue Severity Scale (FSS) is a nine-item
scale that measures the effect of fatigue on daily living
using statements, such as ‘‘I am easily fatigued.
Possible responses range from one (‘‘completely
disagree’’) to seven (‘‘completely agree’’) (Schwartz,
Jandorf, & Krupp, 1993). Subjects with a mean score
of four or more were identified as suffering from signif-
icant fatigue. The Turkish FSS scale has a Cronbach’s
alpha reliability coefficient of 0.85 and internal consis-
tency of 0.94 (Gencay-Can & Can, 2012).
Interventions
Consistency of the aromatherapy massage and reflex-
ology interventions was ensured by using one individ-
ual (the PI) to collect data and administer treatments
using the same intervention technique. Aromatherapy
massage and reflexology were administrated to sub-
jects by the PI, a certified aromatherapy massage,
reflexology practitioner, and registered nurse. The con-
trol group did not receive any sham interventions and
usual care was continued. Aromatherapy massage and
reflexology were performed during home visits in a
quiet room and at a convenient time for subjects. All
study subjects continued to follow their routine RA
treatments during the study. However, subjects were
asked not to take analgesic drugs on the days of the
intervention.
Aromatherapy Massage. The aromatherapy mas-
sage essential oil was a 5% mixture consisting of Lavan-
dula augustifolia,Juniperus communis,Cananga
odorata,andRosmarinus officinalis in the ratio
3:3:2:2 in 100 mL of coconut carrier oil (Buckle, 1999;
Chang, 2008)(Tab l e 1). The choice of essential oils
was determined in consultation with the Department
of Pharmacology, based on a review of the literature
(Faixov & Faix, 2008; Kang & Kim, 2008; T
umen &
Hafızo
glu, 2003).
Before beginning the aromatherapy massage, sub-
jects were placed in a supine position. The aroma-
therapy oils were applied topically to both knees.
The PI remained seated on the same side as the inter-
vention knee. The first part of the massage was initi-
ated with superficial effleurage from the foot
superiorly, including the ankle and knee joint area,
for 3 minutes before applying essential oils. In the sec-
ond part of the massage, the knee area was divided into
four equal quadrants (with an imaginary plus sign pass-
ing midpatella). Five drops of the essential oil blend
were applied to each quadrant (total 20 drops) with
both hands and with circular movements on the
knee for a total of 6 minutes. The third part of the mas-
sage technique was an additional 6 minutes of massage
with five drops of essential oil blend for each quadrant
(total 20 drops) of the right knee. After completing the
15-minute aromatherapy massage session for the right
knee, the massage was repeated on the left knee. The
total duration of aromatherapy massage was
TABLE 2.
Disease and Baseline Characteristics of Subjects (N ¼51)
Characteristic
Aromatherapy Reflexology Control
c
2
,pn%n%n%
Time since RA diagnosis (years) (10.7 7.8)
<10 7 41.1 12 70.6 9 52.9
$10 10 58.9 5 29.4 8 47.1 0.000, 1.000
Pain score (5.9 1.88)
4–6 11 64.7 11 64.7 12 70.6 0.176, .916
7–10 6 35.3 6 35.3 5 29.4
Fatigue score (5.60 0.85)
4-5.6 7 41.1 8 52.9 11 64.7 2.040, .361
5.7-7 10 58.9 9 47.1 6 35.3
DAS28 score (2.82 0.88)
<2.6 8 47.1 5 29.4 7 41.2 1.152, .562
>2.7 9 52.9 12 70.6 10 58.8
RA treatment protocol
DMARD 8 47.1 8 47.1 8 47.1 0.000, 1.000
DMARD þSteroid 9 52.9 9 52.9 9 52.9
144 Gok Metin and Ozdemir
30 minutes. Aromatherapy massage was provided
three times each week for a 6-week period.
Reflexology. Before the intervention, subjects were
placed in a supine position. During reflexology, the
PI sat on a chair facing the subjects’ feet, with the
feet at the PI’s chest level. Relaxation techniques
were administered first to the right foot for 5 minutes.
After relaxation, all reflex points and the region associ-
ated with the pituitary gland on the right foot were
stimulated with thumb pressing, finger pressing, rub-
bing, stroking, and squeezing for 3 minutes. Subse-
quently, 12 minutes were spent stimulating the
specific areas of the foot associated with the head,
neck, shoulders, pineal, pituitary gland, solar plexus,
spinal column, knees, and spleen using the same
reflexology techniques. After completion of the right
foot, the same steps were repeated for the left foot.
Reflexology was applied for 20 minutes on each foot,
for a total of 40 minutes. Treatment was continued
once weekly for a 6-week period.
Data Analysis
Data analyses were conducted using SPSS version 22.00
(SPSS, Inc, Chicago, IL, USA). A pvalue of <.05 was
considered significant. Parametric data, such as subjects’
pain and fatigue scores, were compared with ANOVA
test. Nonparametric data, such as sex, educational level,
and exercise status were compared with frequency and
Chi-square comparisons. Tukey’s HSD post-hoc test
was performed for defining the differences.
TABLE 3.
Demographic Characteristics of Subjects (N ¼51)
Characteristic
Aromatherapy Reflexology Control
n%n%n%
Age (years) (mean ¼54.4 1.2)
18–60 11 64.7 11 64.7 11 64.7
$61 6 35.3 6 35.3 6 35.3
Sex
Female 15 88.2 15 88.2 15 88.2
Male 2 11.8 2 11.8 2 11.8
Educational level
Primary school 10 58.9 10 58.8 11 64.7
High school 3 17.6 2 11.8 2 11.8
University 4 23.5 5 29.4 4 23.5
Employment
Employed 3 17.6 4 23.5 2 11.8
Retired 4 23.5 3 17.6 3 17.6
Unemployed 10 58.9 10 58.9 12 70.6
Smoking
Active 4 23.6 4 23.6 2 11.8
Never 10 58.8 9 52.8 9 52.9
Past 3 17.6 4 23.6 6 35.3
Exercise
3 times/week 3 17.6 0 0.0 2 11.8
<2 times/week 2 11.8 8 47.1 3 17.5
Irregular 8 47.1 5 29.4 8 47.2
No exercise 4 23.5 4 23.5 4 23.5
Comorbidity
Hypertension 8 53.3 6 40.0 4 26.7
Coronary artery disease 2 13.3 6 40.0 2 13.3
Diabetes mellitus 4 26.7 1 6.7 2 13.3
Hyperlipidemia 2 13.3 2 13.3 2 13.3
Complementary therapy
Experienced 8 47.1 5 29.4 6 35.3
Nonexperienced 9 52.9 12 70.6 11 64.7
Complementary therapy type
Spa/hot spring 5 62.5 4 80.0 5 83.3
Massage 0 0.0 0 0.0 1 16.7
Herbal therapy 3 37.5 0 0.0 0 0.0
Cupping 0 0.0 1 20.0 0 0.0
145Aromatherapy Massage and Reflexology in Rheumatoid Arthritis
RESULTS
Subjects’ Demographic and Disease
Characteristics
Disease and baseline scores for the three groups are
shown in Table 2. The mean duration of diagnosis was
10.7 7.8 years. The mean score for pain was 5.9
1.88 years; mean score for fatigue was 5.6 0.85 years;
and mean score for DAS28 was 2.82 0.88. Regarding
treatments, all subjects were taking either DMARD or
DMARD plus steroids. There were no significant differ-
ences in RA characteristics or in the baseline parame-
ters among the three groups (p>.05).
As shown in Table 3, subjects’ mean age was
54.4 1.2 years (range 21–89 years). The great major-
ity of the subjects were female (88.2%), with only 2
men in each study group. The preponderance of sub-
jects in all groups was unemployed (mean: 62.8%).
More than half of the all subjects had never smoked.
An average of 41.2% of subjects did not exercise regu-
larly, and almost 24% of subjects in each study group
stated they never exercise. Comorbidities varied
somewhat by group. The aromatherapy massage group
showed hypertension and diabetes mellitus as the most
common comorbidities, whereas the reflexology
group showed hypertension and coronary artery dis-
ease as more common. In the control group, hyperten-
sion was the most common comorbidity. Hypertension
was the most common comorbidity for all three study
groups. Although women were more likely than men
to have used complementary therapies, more than
half of all subjects had never used any complementary
therapy. Of those who did use complementary therapy,
the most commonly used was spa/hot spring.
Intervention Effects
At the end of the monitoring period, the analysis
showed a statistically significant decrease in VAS and
FSS scores among the intervention groups compared
with the control group (p<.05). Specifically, aroma-
therapy massage significantly decreased pain scores
beginning the second week of the study. Reflexology
findings showed significantly decreased pain scores
TABLE 4.
Comparison of Mean Pain Scores in Intervention and Control Groups (N ¼51)
Measurement Time Patient Group N VAS X ± SD F p
*Difference
(Tukey’s Test)
Baseline Aromatherapy 17 6.00 1.96 0.500 .610
Reflexology 17 6.35 2.17 -
Control 17 5.70 1.44
First week Aromatherapy 17 3.88 1.57 5.216 .009
Reflexology 17 2.38 2.02 2-3
Control 17 4.53 2.29
Second week Aromatherapy 17 3.00 1.73 7.573 .001
Reflexology 17 2.03 1.78 3-1,2
Control 17 5.00 3.04
Third week Aromatherapy 17 2.65 1.45 6.435 .003
Reflexology 17 2.00 1.73 3-1,2
Control 17 4.29 2.44
Fourth week Aromatherapy 17 2.18 1.81 8.305 .001
Reflexology 17 2.18 1.77 3-1,2
Control 17 4.56 2.27
Fifth week Aromatherapy 17 2.24 1.34 12.968 .001
Reflexology 17 1.53 1.46 3-1,2
Control 17 4.59 2.47
Sixth week Aromatherapy 17 1.59 1.17 22.652 .001
Reflexology 17 0.56 1.14 3-1,2
Control 17 4.29 2.38
*1 ¼aromatherapy, 2 ¼reflexology, 3 ¼control.
146 Gok Metin and Ozdemir
beginning the first week of the study (Table 4). Like-
wise, aromatherapy massage significantly reduced fa-
tigue scores beginning the fourth week of the study.
Reflexology reduced fatigue scores beginning the first
week of the study (Table 5).
The effects of the reflexology intervention were
earlier than for aromatherapy massage. In addition,
the pain scores were significantly lower each week
(except for week 4) for subjects who received the
reflexology intervention compared with subjects
who received aromatherapy massage. Similar findings
were seen with fatigue scores. The fatigue scores
were significantly lower each week for subjects who
received the reflexology intervention compared
with subjects who received aromatherapy massage
(Tables 4 and 5).
DISCUSSION
This study demonstrated that aromatherapy massage
and reflexology were superior to a no- intervention
control in reducing pain and fatigue scores. In
addition, reflexology appears to have a greater effect
than aromatherapy massage for reducing pain and fa-
tigue scores in RA subjects.
There was a significant reduction in the interven-
tion groups’ mean pain scores compared with the con-
trol group throughout the intervention period,
beginning the first week for reflexology and the sec-
ond week for aromatherapy massage. Similar to current
study results, aromatherapy massage administered to
RA subjects for two consecutive evenings reduced
pain in a randomized controlled study (Brownfield,
1998). In a quasi-experimental study, aromatherapy
massage significantly decreased pain scores of RA sub-
jects (Kim et al., 2005). Similarly, a quasi-experimental
study found that aromatherapy massage administered
for 4 weeks reduced the number of tender and swollen
joints and pain scores in subjects with RA (Han et al.,
2010). Regarding reflexology, a case report using
reflexology for subjects with RA noted a decrease in
pain after the first session (Khan et al., 2006).
In the current study, pain reduction in aroma-
therapy massage started later compared with
TABLE 5.
Comparison of Mean Fatigue Scores in Intervention and Control Groups (N ¼51)
Measurement Time Patient Group n FSS X ± SD F p
*Difference
(Tukey’s Test)
Baseline Aromatherapy 17 5.86 0.71 1.449 .245 -
Reflexology 17 5.58 0.98
Control 17 5.37 0.82
First week Aromatherapy 17 4.75 0.76 4.296 .019 2-3
Reflexology 17 4.24 1.41
Control 17 5.30 0.85
Second week Aromatherapy 17 4.48 0.85 11.477 .001 2-1,3
Reflexology 17 3.26 1.45
Control 17 5.11 1.03
Third week Aromatherapy 17 4.08 1.08 8.828 .001 2-3
Reflexology 17 3.17 1.64
Control 17 4.97 0.88
Fourth week Aromatherapy 17 3.49 1.18 7.745 .001 3-1,2
Reflexology 17 2.82 1.75
Control 17 4.82 1.51
Fifth week Aromatherapy 17 3.48 1.12 11.078 .001 3-1,2
Reflexology 17 2.54 1.51
Control 17 4.64 1.24
Sixth week Aromatherapy 17 2.94 1.13 13.873 .001 3-1,2
Reflexology 17 1.88 1.18
Control 17 4.41 1.79
*1 ¼aromatherapy, 2 ¼reflexology, 3 ¼control.
147Aromatherapy Massage and Reflexology in Rheumatoid Arthritis
reflexology. This delayed effect may be due to essential
oils’ slow absorption by inflamed joints or differential
response times among individuals to aromatherapy
massage. Reflexology’s rapid impact can be attributed
to its effects on nerves and joints, and stimulation of
the entire body immediately after intervention (Khan
et al., 2006; Taha & Ali, 2011).
According to the results of this study, reflexology
is more effective than aromatherapy massage at
reducing fatigue scores from the beginning of the inter-
vention. Nonetheless, aromatherapy massage also
decreased fatigue scores, starting the fourth week of
the study. This result confirms previous work and
may be interpreted as indicating that reflexology has
a quick effect on the body (Otter et al., 2010). Also,
reflexology decreased pain scores starting the first
week, and this led to relief of fatigue associated with
pain.
Limitations
This study had some limitations. First, the PI collected
the data for both the control and experimental groups
and administered all the interventions. This could be a
potential bias. Another limitation was the homoge-
neous nature of the sample, which makes findings diffi-
cult to generalize to all subjects with RA. Third, this
study protocol occurred over 6 weeks with no
follow-up, so the long-term effects are unknown.
Therefore, a study identifying the long-term effects
would be better able to describe the full impact of
the interventions. Finally, the effects of aromatherapy
massage and reflexology were examined only for pain
and fatigue symptoms, so it is not known whether
other symptoms may be equally impacted by these
interventions.
CONCLUSIONS AND IMPLICATIONS
FOR NURSING
This study is intended to demonstrate the effectiveness
of aromatherapy massage and reflexology as pain and
fatigue relief in a real-world setting such as a rheuma-
tology clinic, and to justify their introduction in the
field of rheumatology.
In this study, aromatherapy massage and reflex-
ology significantly decreased pain and fatigue symp-
toms in subjects with RA in the short term. Thus,
the study confirms that aromatherapy massage and
reflexology can be applied as nonpharmacologic
methods for managing pain and fatigue in subjects
with RA. Based on the study results, aromatherapy
massage and reflexology may be beneficial for RA sub-
jects. Moreover, these complementary treatments are
useful for nurses who can apply aromatherapy mas-
sage and reflexology as a component of care for
symptom management in RA subjects. However, prac-
titioner training and experience with aromatherapy
massage and reflexology are critical to achieving suc-
cessful results.
The authors suggest that future research should
explore aromatherapy massage and reflexology for
other RA symptoms such as joint immobility, sleep
disturbance, and depression to provide more compre-
hensive care for subjects with RA.
Acknowledgments
The authors are grateful to the people who participated in
the study; Umut Kalyoncu, MD, who helped recruit study
subjects in the rheumatology clinic; and Marie Bakitas,
DNSc, CRNP, who edited the manuscript.
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149Aromatherapy Massage and Reflexology in Rheumatoid Arthritis
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In an attempt to redress the lack of research into the use of complementary therapy in the nursing care of patients with rheumatoid arthritis, the author studied the effects of massage and aromatherapy on patients' wellbeing.
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Purpose: The aim of the present study was to examine the effects of a 4-week aromatherapy on pain and inflammation in patients suffering from rheumatoid arthritis. Methods: A quasi-experimental study using a nonequivalent control group, pretest-posttest non-synchronized design was used. To analyze the data, descriptive statistics, Chi-square test, independent samples t-test, and Fisher's exact test were used. Results: After a 4-week aromatherapy, tender joint count (M=5.67 to 4.17), swollen joint count (M=4.13 to 2.54), and patient's assessment of pain (M=43.33 to 31.08) decreased significantly for the aromatherapy participants compared to the control group. But there was no significant difference between the groups in erythrocyte sedimentation rate. Conclusion: These findings suggest that aromatherapy could decrease joint pain, tenderness, and swelling in patients with rheumatoid arthritis, but some modifications in aromatherapy intervention and research method will be required to examine the effects of aromatherapy on inflammatory level in this population.
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Fatigue is a common and potentially distressing symptom for people with rheumatoid arthritis with no accepted evidence based management guidelines. Non-pharmacological interventions, such as physical activity and psychosocial interventions, have been shown to help people with a range of other long-term conditions to manage subjective fatigue. To evaluate the benefit and harm of non-pharmacological interventions for the management of fatigue in people with rheumatoid arthritis. This included any intervention that was not classified as pharmacological in accordance with European Union (EU) Directive 2001/83/EEC. The following electronic databases were searched up to October 2012, Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; AMED; CINAHL; PsycINFO; Social Science Citation Index; Web of Science; Dissertation Abstracts International; Current Controlled Trials Register; The National Research Register Archive; The UKCRN Portfolio Database. In addition, reference lists of articles identified for inclusion were checked for additional studies and key authors were contacted. Randomised controlled trials were included if they evaluated a non-pharmacological intervention in people with rheumatoid arthritis with self-reported fatigue as an outcome measure. Two review authors selected relevant trials, assessed risk of bias and extracted data. Where appropriate, data were pooled using meta-analysis with a random-effects model. Twenty-four studies met the inclusion criteria, with a total of 2882 participants with rheumatoid arthritis. Included studies investigated physical activity interventions (n = 6 studies; 388 participants), psychosocial interventions (n = 13 studies; 1579 participants), herbal medicine (n = 1 study; 58 participants), omega-3 fatty acid supplementation (n = 1 study; 81 participants), Mediterranean diet (n = 1 study; 51 participants), reflexology (n = 1 study; 11 participants) and the provision of Health Tracker information (n = 1 study; 714 participants). Physical activity was statistically significantly more effective than the control at the end of the intervention period (standardized mean difference (SMD) -0.36, 95% confidence interval (CI) -0.62 to -0.10; back translated to mean difference of 14.4 points lower, 95% CI -4.0 to -24.8 on a 100 point scale where a lower score means less fatigue; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 4 to 26) demonstrating a small beneficial effect upon fatigue. Psychosocial intervention was statistically significantly more effective than the control at the end of the intervention period (SMD -0.24, 95% CI -0.40 to -0.07; back translated to mean difference of 9.6 points lower, 95% CI -2.8 to -16.0 on a 100 point scale, lower score means less fatigue; NNTB 10, 95% CI 6 to 33) demonstrating a small beneficial effect upon fatigue. For the remaining interventions meta-analysis was not possible and there was either no statistically significant difference between trial arms or findings were not reported. Only three studies reported any adverse events and none of these were serious, however, it is possible that the low incidence was in part due to poor reporting. The quality of the evidence ranged from moderate quality for physical activity interventions and Mediterranean diet to low quality for psychosocial interventions and all other interventions. This review provides some evidence that physical activity and psychosocial interventions provide benefit in relation to self-reported fatigue in adults with rheumatoid arthritis. There is currently insufficient evidence of the effectiveness of other non-pharmacological interventions.
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The purpose of this work was to identify what effect reflexology has on foot pain and quality of life (QoL) in a patient with rheumatoid arthritis (RA). Using an observational case report, a 6-week course of reflexology treatments were given to a patient who has RA. Perceived pain and QoL were assessed using two validated outcome measures: the Rheumatoid Arthritis Quality of Life (RAQoL) questionnaire and the Foot Pain Disability Questionnaire (FPDQ). The RAQoL scores demonstrated no significant change throughout the duration of the investigation, suggesting that the patient's QoL did not change during or at the end of the 6-week course of reflexology. Scores from the FPDQ indicated reflexology was associated with a reduction in foot pain described by the subject. The clinical implications are that reflexology may be a valuable addition in the management of foot pain for participants with RA. However, it is impossible to generalize from a observational case report and further work is recommended.
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Essential oils, made out of natural aromatic molecules, are endowed with so many physiological and pharmacological properties that they find applications in almost every field of medicine, not only curatively but also from a preventative medicine point of view. Although the perception of, and reaction to, essential oils seems to be slightly different between women and men, all people of all ages benefit from aromatherapy. Provided that the practitioner has the relevant information and has undergone the appropriate training, and that the aromatic extracts used conform to medical quality criteria, aromatherapy and aromatology can bring real complementary help to many patients, far beyond the anti-stress massage approach.Aromatherapy can provide a useful complementary medical service both in healthcare settings and in private practice, e.g. in cancer care, dementia, and depression. There are also many indications for the useful and successful application of essential oils, especially for men, such as stress, sleep disorders, back pain, urinary tract infections, rectal abscess, and sexual health.