Background and Purpose. Patients undergoing kidney transplantation surgeries suffer from postoperative pain, fatigue, and sleep disorders. Therefore, it is necessary to use different interventions in addition to modern medicine to reduce their symptoms. The present study aimed to investigate the effect of foot reflexology on pain, fatigue, and quality of sleep after kidney transplantation surgery. Materials and Methods. The study was a parallel randomized controlled trial. Patients admitted to the transplantation ward participated in the study. Fifty-three eligible patients were allocated into the foot reflexology group (n = 26) and the control group (n = 27) by using the stratified randomization method. Finally, 25 participants in each group finished the study. The intervention group received foot reflexology for 30 minutes once a day for three consecutive days, and no reflexology was applied in the control group. The intervention started on the second day after surgery. Pain, fatigue, and quality of sleep were measured on the first, second (before intervention), third, fourth, and eleventh days after surgery. Data were collected using visual analogue scale for measuring pain and fatigue and Verran and Snyder-Halpern sleep scale for measuring quality of sleep. Results. In each group, 25 patients finished the study. The mean pain score in the foot reflexology and control groups decreased from 9.44 ± 0.96 and 9.36 ± 0.91 on the day of surgery to 1.32 ± 0.94 and 4.32 ± 1.68 on the eleventh day after surgery, respectively. The mean fatigue score in the reflexology and control groups decreased from 8.76 ± 1.27 and 8.6 ± 1.26 on the day of surgery to 1.24 ± 1.2 and 3.92 ± 1.63 on the eleventh day after surgery, respectively. The mean sleep score in the foot reflexology and control groups increased from 33.38 ± 11.22 and 39.59 ± 12.8 on the day of surgery to 69.43 ± 12.8 and 56.27 ± 8.03 on the eleventh day after surgery, respectively. While pain, fatigue, and sleep quality scores improved in both groups, those in the intervention group showed significantly greater improvement compared with the control group (). No significant difference was found between the two groups in the use of acetaminophen on the first, second, third, fourth, and eleventh days after surgery (). Conclusion. Foot reflexology may reduce pain and fatigue and improve sleep quality of patients after kidney transplantation.
Kidney transplantation is the most effective treatment for end-stage kidney disease worldwide . According to the statistics from the Global Observatory on Donation and Transplantation, the cases of kidney transplantation were 90,306 worldwide in 2017 . In Iran, 48.8% of kidney failure patients are undergoing kidney transplantation . Evidence suggests that successful kidney transplantation can improve quality of life, life expectancy, and reduce health costs . However, patients may experience different physical difficulties such as cardiovascular and neurologic complications , sexual dissatisfaction , or mental disorders such as anxiety, depression, or stress . Patients may also experience postoperative pain, fatigue, and sleep disorders .
Some patients experience severe pain on their back, chest, inguinal area, the surgery area, and head after kidney transplantation surgery [9, 10], and postsurgical pain is a major therapeutic problem in these patients . This pain may become worse if not managed properly . An inverse association is available between pain and blood pressure, and uncontrolled postoperative pain leads to hypotension and other postoperative disorders . Fatigue and lack of energy are other common postoperative symptoms . Few studies have shown that patients under kidney transplantation experience more fatigue than healthy subjects . The prevalence of postoperative fatigue was 48.3% in one study, which was 41.5% three months later and 38.1% six months later . Fatigue can affect quality of sleep of kidney transplant recipients. On the other hand, sleep deprivation in these patients can cause fatigue, depression, pain, and stress [17, 18].
Different complementary and alternative medicine (CAM) methods such as foot reflexology are used for managing symptoms among some patients after kidney transplantation . Foot reflexology is a special form of massage that accompanies with the pressure of the fingers, especially the thumbs on the reflex areas usually in the feet. These areas are believed to associate with all parts of the body, and applying pressure on them can affect the physiological responses of the body. They are thought to improve recovery and return homeostasis . Foot reflexology can regulate blood circulation and hemodynamic variables . The underlying mechanisms of reflexology are not well understood. Reflexology is assumed to facilitate relaxation, release endorphins, and modulate pain-impulse transmission and pain perception . Subsequently, relaxation can effect quality of sleep and fatigue [23–25]. In addition, touch and massage of reflex points in the foot may reduce patients’ pain. Diseases are caused by the blockage of energy in the body, and stimulation of reflex points may eliminate these obstructions and release energy in the body .
Several studies have examined the effects of foot reflexology on symptoms such as pain, fatigue, and quality of sleep of patients [19, 27–30]. Other studies showed a positive effect of foot reflexology on pain and anxiety of patients after general and spinal surgery [29, 30] and during chemotherapy and after breast cancer surgery [31, 32]. Different studies showed the positive effects of reflexology on alleviating fatigue in patients [33, 34]. Asltoghiri et al. showed the improvement of sleep disorders using reflexology . Lee considered foot reflexology as a useful intervention to decrease fatigue and promote quality of sleep . Moreover, the results of a systematic review showed that reflexology was safe and effective for insomnia, but further studies with greater accuracy and power are needed .
The complementary and alternative therapies have been increasingly used in recent decades, and nurses prefer to use noninvasive methods with minimal side effects . Since reflexology does not have major side effects , nurses can use it to improve the quality of nursing care. However, decisions are still being made with caution due to insufficient research studies. No study has investigated the effect of reflexology on pain, fatigue, and quality of sleep after kidney transplantation; therefore, the current study tested the hypothesis that the mean scores of pain, fatigue, and quality of sleep in patients after kidney transplantation surgery were different between the foot reflexology and control groups after the intervention and one week later.
2. Materials and Methods
2.1. Study Type and Setting
This study was a parallel randomized controlled trial. Patients taken to the transplantation department of Afzalipour Hospital, Kerman, Iran, were studied from April 2018 to May 2019.
2.2. Sample Size and Sampling
According to a pilot study (5 samples in each group) (on the fourth day after surgery, the mean and standard deviation in the pilot reflexology group were 3.2 ± 2.17 and the mean and standard deviation in the pilot control group were 5.2 ± 1.3), the sample size was estimated to be 21 individuals for each group with a confidence coefficient of 95% and type II error of 10%. Due to the probability of dropout, 25 samples were selected in each group. It is noteworthy that the pilot samples were included in the final analysis. Furthermore, power analysis calculated with Power software indicates that (power = 90%, ) 46 participants would be needed (23 per group) to detect an effect size of 0.2. Inclusion criteria were the minimum age of 15 years old, the first turn of the kidney transplantation, no ulcers or injuries in feet, especially the sole, complete postoperative consciousness, no history of using foot reflexology, no addiction to drug use or alcohol, and no mental disorder. Exclusion criteria were the patient’s return to the operating room during the study, the patient’s need to a sedative, and any symptoms indicative of transplant rejection (with the doctor’s diagnosis). Sixty patients were examined for the inclusion criteria, of whom seven were not eligible due to different reasons such as a second transplant, no age fulfillment, and mental disorder. In addition, there were three dropouts due to returning to the operating room and rejection of the transplant. Finally, 25 samples in each group completed the study, and their data were analyzed (Figure 1). Eligible patients were selected by convenience sampling and allocated to the intervention and control groups with the stratified randomization method using gender and age (±2) as strata. In other words, the first sample was randomly allocated either to the intervention or control groups (using the lottery), and the subsequent samples were randomly allocated to both groups according to the matching variables. The first author assessed the participants according to the inclusion criteria and allocated them into the groups.