Effect of Foot Reflexology Intervention on Depression, Anxiety, and Sleep Quality in Adults: A Meta-Analysis and Metaregression of Randomized Controlled Trials

Abstract

Objectives:
The aim of this study was to conduct a systematic review, meta-analysis, and metaregression to determine the current best available evidence of the efficacy and safety of foot reflexology for adult depression, anxiety, and sleep quality.

Methods:
Electronic databases (PubMed, ClinicalKey, ScienceDirect, EMBASE, PsycINFO, and the Cochrane Library) were searched till August, 10, 2020, and the validity of the eligible studies was critically appraised. Randomized controlled trials comparing foot reflexology groups with control groups for adult depression, anxiety, and sleep quality were included. Twenty-six eligible studies were included to assess the effect of foot reflexology intervention on the reducing symptoms of depression and anxiety and improving quality of sleep, respectively, as the primary outcome.

Results:
Twenty-six randomized controlled trials involving 2,366 participants met the inclusion criteria. The meta-analyses showed that foot reflexology intervention significantly improved adult depression (Hedges' g = -0.921; 95% CI: -1.246 to -0.595; P < 0.001), anxiety (Hedges' g = -1.237; 95% CI -1.682 to -0.791; P < 0.001), and sleep quality (Hedges' g = -1.665; 95% CI -2.361 to -0.970; P < 0.001). Metaregression reveals that an increase in total foot reflexology time (P = 0.002) and duration (P = 0.01) can significantly improve sleep quality.

Conclusions:
Foot reflexology may provide additional nonpharmacotherapy intervention for adults suffering from depression, anxiety, or sleep disturbance. However, high quality and rigorous design RCTs in specific population, along with an increase in participants, and a long-term follow-up are recommended in the future.

Full text

Research Article
Effect of Foot Reflexology Intervention on Depression,
Anxiety, and Sleep Quality in Adults: A Meta-Analysis and
Metaregression of Randomized Controlled Trials
Wei-Li Wang,
1
Hao-Yuan Hung,
2
,
3
,
4
Ying-Ren Chen,
5
,
6
Kuang-Huei Chen,
1
Szu-Nian Yang,
1
,
7
,
8
Chi-Ming Chu,
9
and Yuan-Yu Chan
1
,10
1
Department of Psychiatry, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
2
Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan
3
Department of Pharmacy Practice, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
4
Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
5
Department of Nursing, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
6
Graduate Institute of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
7
Tri-Service General Hospital, Beitou Branch, National Defense Medical Center, Taipei, Taiwan
8
Graduate Institute of Health and Welfare Policy, School of Medicine, National Yang-Ming University, Taipei, Taiwan
9
Department of Epidemiology, School of Public Health, National Defense Medical Center, Taipei, Taiwan
10
Department of Psychology, Chung Yuan Christian University, Taoyuan, Taiwan
Correspondence should be addressed to Yuan-Yu Chan; xaviorchan@gmail.com
Received 31 January 2020; Revised 20 August 2020; Accepted 5 September 2020; Published 15 September 2020
Academic Editor: Gerhard Litscher
Copyright ©2020 Wei-Li Wang et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objectives. e aim of this study was to conduct a systematic review, meta-analysis, and metaregression to determine the current
best available evidence of the efficacy and safety of foot reflexology for adult depression, anxiety, and sleep quality. Methods.
Electronic databases (PubMed, ClinicalKey, ScienceDirect, EMBASE, PsycINFO, and the Cochrane Library) were searched till
August, 10, 2020, and the validity of the eligible studies was critically appraised. Randomized controlled trials comparing foot
reflexology groups with control groups for adult depression, anxiety, and sleep quality were included. Twenty-six eligible studies
were included to assess the effect of foot reflexology intervention on the reducing symptoms of depression and anxiety and
improving quality of sleep, respectively, as the primary outcome. Results. Twenty-six randomized controlled trials involving 2,366
participants met the inclusion criteria. e meta-analyses showed that foot reflexology intervention significantly improved adult
depression (Hedges’ g� −0.921; 95% CI: −1.246 to −0.595; P<0.001), anxiety (Hedges’ g� −1.237; 95% CI −1.682 to −0.791;
P<0.001), and sleep quality (Hedges’ g� −1.665; 95% CI −2.361 to −0.970; P<0.001). Metaregression reveals that an increase in
total foot reflexology time (P�0.002) and duration (P�0.01) can significantly improve sleep quality. Conclusions. Foot re-
flexology may provide additional nonpharmacotherapy intervention for adults suffering from depression, anxiety, or sleep
disturbance. However, high quality and rigorous design RCTs in specific population, along with an increase in participants, and a
long-term follow-up are recommended in the future.
1. Introduction
Foot reflexology is a systemic practice in which a practitioner
applies some pressure to any pressure points on the feet to
stimulate the body and provide health benefits to different
parts of the body. Foot reflexology is commonly practiced as
a complementary therapy and is one of the non-
pharmacological therapies to alleviate our mental, emo-
tional, and spiritual health, while improving the quality of
our life [1].
Foot reflexology is a reflexology intervention that has
been applied in different cultures around the world for
Hindawi
Evidence-Based Complementary and Alternative Medicine
Volume 2020, Article ID 2654353, 21 pages
https://doi.org/10.1155/2020/2654353

thousands of years. It is defined as a type of therapy that is
based on the stimulation of the nerves and circulatory
system of the body in which all the reflexology points,
corresponding to different parts of the human body, are
considered [2]. It is still ambiguous regarding the mecha-
nism behind the function of foot reflexology, but it certainly
has been shown to have potent physiological and psycho-
logical effects, perhaps attributed to the relaxation derived
from the placebo effect, the therapeutic communication
techniques, and impact of touching behavior. e explica-
tion for the mechanism of action in foot reflexology is based
on the theory that helps to equilibrate the energy in the
whole physical structure [3, 4]. Currently, the most prom-
ising theory suggests that the benefits of foot reflexology may
be caused by modulating our autonomic nervous system [5].
e effects are well known to relieve the psychological
symptoms of stress by reducing anxiety and muscle tension
[6], calming our mood [7], improving the quality of sleep [8],
and facilitating the feeling of well-being [9]. Pharmaco-
logical treatment of prevalent symptoms such as depression,
anxiety, and sleep disturbance may contribute to the high
strain on the body, creating additional side effects [10]. Foot
reflexology provides an advantage to certain groups and
generally does not cause any damaging effects during certain
medical circumstances. Every person’s body circumstance is
unique, so outcomes from foot reflexology intervention
could differ from one person to another [11].
e previous systematic review had reported physio-
logical and biochemical outcomes associated with foot re-
flexology intervention [12]. However, there are insufficient
number of evidence-based studies that expound the effects of
foot reflexology on improving our psychological symptoms
such as depression, anxiety, and sleep disturbance. To our
knowledge, this is the first systematic review and meta-
analysis on the psychological effect of foot reflexology and to
identify the possible related factors of foot reflexology in
adult participants.
2. Methods
2.1. Reporting Standards. e present study was designed,
executed, and adopted in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-analyses
(PRISMA) statement guidelines [13] and the suggestions by
the Cochrane Collaboration [14]. e protocol for this
systematic review and meta-analysis is registered with
PROSPERO under registration number CRD42020162545.
2.2. Eligibility Criteria
2.2.1. Types of Studies. Randomized controlled trials (RCTs),
randomized crossover trials, and cluster randomized trials
all met our inclusion criteria. e language of the studies was
restricted to English.
2.2.2. Types of Participants. Adults aged 18 years or older
without restrictions on sociodemography, race, gender, or
health status were participants. All studies that reported on
depression, anxiety, or sleep quality were included. ere
was no restriction on the baseline for these.
2.2.3. Types of Interventions. No further restrictions were
made regarding the foot reflexology zone, constitution,
length, frequency, or duration of intervention programs.
Studies on cointerventions that included foot reflexology as a
part of multimodal interventions were excluded because it
would be hard to evaluate the influence of foot reflexology
from additional modalities. Shame intervention, care-as-
usual, nontreatment waitlists, and psychoeducation about
depression, anxiety, or sleep hygiene information are con-
sidered as the nonactive control group.
2.2.4. Types of Outcome Measures. Studies include, at least,
one efficacy outcome index related to depression, anxiety,
and sleep quality. Our primary outcome measures of this
study were depression, anxiety, and sleep disturbance. Data
are presented both at baseline and after intervention. We
take various clinical outcomes that were informed in the
selected RCTs to show improvements in the symptoms of
depression, anxiety, and sleep disturbance into consider-
ation. No restrictions were set on the scales of measurement
used to evaluate these outcomes because a wide variety of
measures in the outcomes were applied in the studies.
Our secondary outcome of this study was intervention
safety, which assessed the number of participants with ad-
verse events, including serious adverse events or nonserious
events. Adverse events resulting in death, life-threatening
situations, hospitalization, disability or permanent damage,
congenital anomaly/birth defect, or the need for medical or
surgical intervention to prevent the aforementioned out-
comes were defined as serious [15]. All other adverse events
were regarded as nonserious.
2.3. Search Methods. e following electronic databases
were searched from their inception to August 10, 2020:
PubMed, ClinicalKey, ScienceDirect, EMBASE, PsycINFO,
and the Cochrane Library. e search was performed using
the keywords “foot reflexology,” “depression,” “anxiety,” and
“sleep quality.” e complete search through PubMed was
conducted using the medical subjective headings (MeSHs) as
follows: (foot reflexology [MeSH] OR foot reflexology [Title/
Abstract] OR foot massage [MeSH] OR foot massage [Title/
Abstract] OR reflexology [MeSH] OR reflexology [Title/
Abstract]) AND (depression [MeSH] OR depression [Title/
Abstract] OR depressive disorder [MeSH] OR depressive
disorder [Title/Abstract] OR anxiety [MeSH] OR anxiety
[Title/Abstract] OR anxiety disorder [MeSH] OR anxiety
disorder [Title/Abstract] sleep quality [MeSH] OR sleep
quality [Title/Abstract] OR insomnia [MeSH] OR insomnia
[Title/Abstract] OR sleep disturbance [MeSH] OR sleep
disturbance [Title/Abstract]). e search strategy was
adapted for each database as necessary.
e references of our retrieved studies and previous
systematic reviews were manually screened to ensure a
comprehensive search. Additionally, Google Scholar search
2Evidence-Based Complementary and Alternative Medicine

engine was utilized to identify extra articles that had not yet
been included in the previously mentioned electronic
databases.
e titles and abstracts were scanned independently by
two independent reviewers. When there was disagreement
on eligibility, we discussed with a third reviewer to reach a
consensus.
2.4. Data Extraction Method. Two reviewers independently
extracted general information from the aforementioned
selected publications on design and study sample (e.g., ar-
ticle setting, first author’s name/year of publication, and
origin), participants (e.g., mean age, gender, clinical char-
acteristics, comorbid conditions, and the number of par-
ticipants), interventions (e.g., foot reflexology zone,
components, frequency, duration, and length of foot re-
flexology), control interventions (e.g., shame intervention,
treatment-as-usual, and waitlist), and outcomes (e.g., out-
come measurement tools, measured outcomes, adherence,
eventual follow-up time, and adverse events). Any dis-
agreements between the two reviewers should refer to the
third reviewer’s opinion.
2.5. Quality and Risk-of-Bias Assessments. Two reviewers
independently assessed the risk of bias in each study. ere
were seven domains of assessment for the risk of bias in-
cluding the following: (1) random sequence generation, (2)
allocation concealment, (3) blinding of participants and
personnel, (4) blinding of outcome assessment, (5) in-
complete outcome data, (6) selective reporting, and (7) other
biases using the Cochrane Systematic Review Manual risk-
of-bias assessment tool [16]. ese rates were then labeled as
“low risk,” “high risk,” or “unclear risk” of bias. A risk-of-
bias table was completed for each included study. To im-
prove accuracy, any disagreements would refer to a third
reviewer’s opinion.
2.6. Data Synthesis and Statistical Analysis. Meta-analysis
was performed using Comprehensive Meta-Analysis Soft-
ware. e random-effects model was used to calculate the
pooled effect size of the included studies. Hedges’ gwas
calculated to determine the effect size [17]. e effect size
represents the difference between two groups in the number
of standard deviations. An effect size of 0.2–0.49 was con-
sidered a small effect, 0.5–0.79 was a moderate effect, 0.8 and
higher was a large effect [18]. e meta-analysis results were
expressed as the pool effect, with corresponding 95% and P
value. e heterogeneity data were evaluated using a ran-
dom-effects model because it accommodated the possibility
that the underlying effect differed across studies.
2.7. Assessment of Heterogeneity. Heterogeneity between
studies was evaluated using the I
2
statistic with a cutoff point
>50%, and a Pvalue ≤0.1 was regarded as a significant degree
of heterogeneity. e most common I
2
scale considered
values lower than 25% as low heterogeneity; values between
25%–50% as mean heterogeneity; values between 50%–74%
as substantial heterogeneity; and values between 75%–100%
as considerable heterogeneity [14]. Random effects of uni-
variate and multivariate meta-regressions were used to ex-
plore the source of heterogeneity if I
2
>50% and Pvalue
≤0.1.
2.8. Moderator Analyses. We performed subgroup meta-
analysis and metaregression analysis to examine possible
sources of heterogeneity and survey the possible con-
founding effects of clinical variables. e subgroup analysis
produced prespecified covariates, including outcome mea-
surement instruments, study quality, and participant details.
Additionally, continuous covariates were obtained from the
metaregression analysis to investigate whether relationships
were linear and consistent with the results of the categorical
analysis. A metaregression model was performed to test
between-subgroup interaction, and a Pvalue <0.05 indicated
a significant difference.
2.9. Risk of Publication Bias. Publication bias was explored if
there were up to ten eligible trials included in the meta-
analysis. Funnel plots generated using Comprehensive
Meta-Analysis Software were estimated from individual
studies against each study’s standard error. e presence of
asymmetry with a visual inspection in funnel plots was
considered potentially indicative of publication bias [19].
Potential publication bias was tested using the calculation of
Egger’s regression method, with Pvalues <0.05 suggesting
the presence of bias.
3. Results
3.1. Research Material. e search strategy identified 959
research articles through electronic databases. A total of 912
records were excluded after removal of duplicates and
screening of abstracts and titles. en, all full-text articles
were evaluated for eligibility, and 21 records were excluded
for reasons such as they were not randomized [20–30], did
not include relevant outcomes [31–33], included foot re-
flexology as a part of a multimodal intervention [34–38],
lacked adequate control group [39], has yet to be officially
published [40]. Finally, 26 remaining articles with 2,366
participants were investigated by qualitative analyses. All
articles were published in English. e flowchart of the study
selection process is presented in Figure 1.
3.2. Characteristics of Eligible Studies. e characteristics of
the 26 eligible studies are presented in Tables 1 and 2. All
study assessed outcomes are listed directly at the end of foot
reflexology intervention. Among the 26 RCTs selected for
our study efficacy, the psychological symptoms of depres-
sion, anxiety, and sleep quality, respectively, were assessed as
the primary outcome. Our studies were conducted in Iran,
Turkey, Taiwan, South Korea, Japan, and Israel. All of the
included studies were published between 2011 and 2020. e
sample sizes ranged from 50 to 189 individuals (total 2,366
participants). e average age ranged from 27 to 72 years,
Evidence-Based Complementary and Alternative Medicine 3

and all the participants were adults (age >18 years). In each
study, foot reflexology intervention for one session lasted
between 10–60 min (total treatment sessions ranged from 1
to 18 in each study). Also, the total treatment periods ranged
from 1 to 8 weeks. Adherence to the foot reflexology was
reported in all studies as the percentage in foot reflexology
session dropouts. Adherence was >90% in all studies. Evi-
dence of safety issue evaluation was limited because only a
few studies report safety-related adverse effects as the sec-
ondary outcome. Most of the included studies failed to
report on this aspect making research difficult.
3.3. Risk of Bias
3.3.1. Quality of Methods. Risk-of-bias assessment is shown
in Table 3. Twenty-six studies were assessed as high or
unclear risk of bias in at least one of the domains. All studies
reviewed stated they were randomized, whether or not this is
true remains uncertain as eight studies did not show their
content and method of random sequencing [7, 41–47]. A
small proportion of studies were low risk due to the state of
detailed randomization and allocation methods [20, 48–52].
Most studies yielded no data material on bias concealment.
One study had insufficient data on attrition rates [44]. We
found no included studies with potential bias in the domain
of selective reporting. Other potential sources of bias were
high in 9 RCTs due to poor compliance, incomplete outcome
data, small sample size, or obvious baseline differences
[41–46, 48, 52, 53].
3.3.2. Publication Bias. e funnel plots on the efficacy of
foot reflexology for psychological symptoms for depression,
anxiety, and sleep disturbance were executed including 4
RCTs, 16 RCTs, 10 RCTs, respectively. e visual inspection
of the funnel plots indicated some risk of publication bias for
the effects of foot reflexology only in the domain of anxiety
symptoms (shown in Figure 2). ose plots examined were
shown to be asymmetrical, suggesting the possible risk of
publication bias. Moreover, results of Egger’s regression test
indicated no significant publication bias (Egger test
intercept � −7.32; P�0.11). erefore, the overall pop-
ulation effect size was likely to be relatively robust.
912 records excluded (duplicated
or failed to meet inclusion criteria)
26 studies included in qualitative
synthesis
364 PubMed(i)
(ii)
(iii)
(iv)
(v)
101 science direct
18 PsycINFO
168 clinicalkey
302 cochrane library
6 additional records identified
through other sources
47 full-text articles assessed for
eligibility
Identification
21 full-text articles excluded
11 not randomized
3 no relevant outcomes
5 combined with other
interventions
1 no adequate control group
1 yet to be officially
published
Included Eligibility
953 records identified through
database searching
Screening
(i)
(ii)
(iii)
(iv)
(v)
Figure 1: Flowchart of the results of the literature search.
4Evidence-Based Complementary and Alternative Medicine

Table 1: Characteristics of included studies.
Authors, year,
country
Main characteristics
of studied
population
Sample
characteristics
(sample size,
mean age)
Sex difference
Intervention
group. vs.
comparison
group
Outcome
measurement tools Outcomes
Valizadeh et al.,
2015, Iran
Participants between
the age of 60–75 y/o
independently
performing daily
activities and having
mental health based
on health records
available in the
health center
69, G1 �23,
G2 �23, G3 �23
mean age:
G1 �66.82 y/o
(SD �4.80),
G2 �67.69 y/o
(SD �4.28),
G3 �66.82 y/o
(SD �3.84)
Male: 69
Female: 0
G1 �foot
reflexology
G2 �footbath
G3 �control
group
Pittsburgh Sleep
Quality Index (PSQI)
e total score of
PSQI improved:
no statistically
significant
finding G1 vs. G3
(P<0.05)
G1 �6.08 (5.27),
G1∗�3.91 (4.04)
G3 �4.69 (0.51),
G3∗�5.69 (3.08)
Lee et al., 2011,
Taiwan
Postpartum women
have given birth
vaginally without
postpartum
complications and
concurrent medical
conditions with poor
sleep condition
(PSQI ≥5)
68, G1 �34,
G2 �34 mean age:
G1 �32.0 y/o
(SD �2.8),
G2 �31.2 y/o
(SD �2.8) (3 drop
out)
Male: 0
Female: 68
G1 �foot
reflexology
G2 �control
group
Pittsburgh Sleep
Quality Index (PSQI)
e total score of
PSQI improved:
G1 vs. G2
(P<0.001)
G1 �9.94 (2.61),
G1∗�3.97 (1.26)
G2 �9.45 (2.59),
G2∗�6.24 (1.68)
Bakir et al.,
2018, Turkey
Voluntary
participants aged
≥18 y/o diagnosed
with rheumatoid
arthritis, at least, 1
year with VAS-Pain
(visual analogue
scale for pain) of 4 or
greater
60, G1 �30,
G2 �30 mean age:
G1 �50.83 y/o
(SD �12.0),
G2 �49.50 y/o
(SD �16.4) (5
drop out)
Male: 14
Female: 46
G1 �foot
reflexology
G2 �control
group
Pittsburgh Sleep
Quality Index (PSQI)
e total score of
PSQI improved:
G1 vs. G2
(P�0.001)
G1 �16.20 (3.70),
G1∗�13.16
(3.57) G2 �16.75
(3.64),
G2∗�19.03
(3.05)
Unal et al.,
2016, Turkey
Patients between the
age of 18–60 y/o who
received
hemodialysis therapy
twice a week without
any communication
problems
105, G1 �35,
G2 �35, G3 �35
mean age:
G1 �51.74 y/o
(SD �12.2),
G2 �53.89 y/o
(SD �13.1),
G3 �54.33 y/o
(SD �12.9)
Male: 55
Female: 50
G1 �foot
reflexology
G2 �back
massage
G3 �control
group
Pittsburgh Sleep
Quality Index (PSQI)
e total score of
PSQI improved:
G1 vs. G3
(P<0.05)
G1 �11.09 (3.18),
G1∗�5.54 (2.15)
G3 �9.20 (2.42),
G3∗�11.88
(2.47)
Zengin et al.,
2018, Turkey
Participants with
cancer have received
at least their first
session of
chemotherapy and
have no diagnosis of
sleep disorder
167, G1 �84,
G2 �83 mean age:
G1 �not
mentioned
G2 �not
mentioned (9
drop out)
Male: 78
Female: 89
G1 �foot
reflexology
G2 �control
group
Pittsburgh Sleep
Quality Index (PSQI)
e total score of
PSQI improved:
G1 vs. G2
(P<0.001)
G1 �12 (2.7),
G1∗�5.5 (2.1)
G2 �11.3 (1.9),
G2∗�13 (2.4)
Rambod et al.,
2019, Iran
Patients with
lymphoma aged
≥18 y/o, being able to
speak Persian and
being willing to
participate in the
study
72, G1 �36,
G2 �36 mean age:
G1 �41.47 y/o
(SD �13.70),
G2 �46.90 y/o
(SD �15.40)
Male: 52
female: 20
G1 �foot
reflexology
G2 �control
group
Pittsburgh Sleep
Quality Index (PSQI)
e total score of
PSQI improved:
G1 vs. G2
(P<0.05)
G1 �10.11 (3.26),
G1∗�8.41 (2.98)
G2 �11.80 (3.83),
G2∗�11.83
(3.26)
Evidence-Based Complementary and Alternative Medicine 5

Table 1: Continued.
Authors, year,
country
Main characteristics
of studied
population
Sample
characteristics
(sample size,
mean age)
Sex difference
Intervention
group. vs.
comparison
group
Outcome
measurement tools Outcomes
Malekshahi
et.al., 2018, Iran
Patients between the
age of 18–65 y/o who
have sleeping
problems on the
basis of the
Pittsburgh
questionnaire,
undergoing
hemodialysis in the
evening and night
shifts
80, G1 �40,
G2 �40 mean age:
G1 �not
mentioned
G2 �not
mentioned
Male: 53
female: 27
G1 �foot
reflexology
G2 �control
group
Pittsburgh Sleep
Quality Index (PSQI)
e total score of
PSQI improved:
G1 vs. G2
(P<0.05)
G1 �11.79 (3.13),
G1∗�6.32 (1.93)
G2 �10.94 (4.10),
G2∗�12.47
(3.94)
Oshvandi et al.,
2014, Iran
Patients between the
age of 30–80 y/o who
have ischemic heart
disease hospitalized
in the critical care
unit
60, G1 �30,
G2 �30 mean age:
G1 �64.17 y/o
(SD �12.04),
G2 �50.50 y/o
(SD �11.40)
Male: 34
Female: 26
G1 �foot
massage
G2 �control
group
St. Mary’s Hospital
Sleep Questionnaire
(SMHSQ)
e total score of
SMHSQ
improved: G1 vs.
G2 (P<0.05)
G1 �19.67 (6.25),
G1∗�15.33
(4.87) G2 �18.93
(5.87),
G2∗�18.90
(5.66)
Samarehfekri
et al., 2020, Iran
Patients undergoing
kidney
transplantation
surgeries suffer from
postoperative pain,
fatigue, and sleep
disorders
50, G1 �25,
G2 �25 mean age:
G1 �38.12 y/o
(SD �12.87),
G2 �38.56 y/o
(SD �12) (3 drop
out)
Male: 34
Female: 16
G1 �foot
massage
G2 �control
group
e Verran and
Snyder-Halpern
Sleep Scale
e total score of
the Verran and
Synder-Halpern
Sleep Scale
improved: G1 vs.
G2 (P<0.05)
G1 �41.98
(SD �13.92),
G1∗�60.60
(SD �10.75)
G2 �42.15
(SD �11.78),
G2∗�52.23
(SD �11.76)
Toygar et al.,
2020, Turkey
Aged 18 years and
above, who are the
primary informal
caregivers of cancer
patients (without any
professional help)
66, G1 �33,
G2 �33 mean age:
G1 �41.52 y/o
(SD �13.88),
G2 �39.02 y/o
(SD �12.80)
Male: 10
Female: 56
G1 �foot
reflexology
G2 �control
group (shame
intervention)
Richard–Campbell
Sleep Questionnaire
(RCSQ) state-trait
anxiety inventory
(STAI)
e total score of
RCSQ improved:
G1 vs. G2
(P<0.05)
G1 �430.3
(SD �43.46),
G1∗�441.8
(SD �35.51)
G2 �441.2
(SD �35.18),
G2∗�409.5
(SD �50.08) the
total score of
STAI improved:
G1 vs. G2
(P<0.05)
G1 �46.67
(SD �7.21),
G1∗�38.91
(SD �5.63)
G2 �47.94
(SD �10.62),
G2∗�46.30
(SD �11.29)
6Evidence-Based Complementary and Alternative Medicine

Table 1: Continued.
Authors, year,
country
Main characteristics
of studied
population
Sample
characteristics
(sample size,
mean age)
Sex difference
Intervention
group. vs.
comparison
group
Outcome
measurement tools Outcomes
Bahrami et al.,
2019, Iran
A female patient
aged ≥60 y/o
diagnosed with acute
coronary syndrome
consisting of angina
pectoris and
myocardia
infraction, no
anxiolytics and
sedative medications
in the last four hours
before the
intervention
90, G1 �45,
G2 �45 mean age:
G1 �72.86 y/o
(SD �7.98),
G2 �72.62 y/o
(SD �7.93)
Male: 0
Female: 90
G1 �foot
reflexology
G2 �control
group
Hospital depression
scale (HADS-D)
hospital anxiety scale
(HADS-A)
e total score of
HADS-D
improved: G1 vs.
G2 (P<0.05)
G1 �13.66
(SD �4.64),
G1∗�8.42
(SD �3.62)
G2 �11.74
(SD �4.29),
G2∗�11.11
(SD �3.42) the
total score of
HADS-A
improved: G1 vs.
G2 (P<0.05)
G1 �13.77
(SD �4.39),
G1∗�8.53
(SD �3.71)
G2 �11.66
(SD �4.24),
G2∗�11.06
(SD �3.19)
Noh et al., 2019,
South Korea
Gynaecologic cancer
patients receiving
chemotherapy and
hospitalized in the
gynaecological ward,
who received short-
term chemotherapy
(at least 2 weeks
chemotherapy)
63, G1 �32,
G2 �31 mean age:
G1 �56.34 y/o
(SD �9.04),
G2 �55.36 y/o
(SD �9.96) (1
drop out)
Male: 0
Female: 63
G1 �self-foot
reflexology
G2 �control
group
Hospital depression
scale (HADS-D);
hospital anxiety scale
(HADS-A)
e total score of
HADS-D
improved: G1 vs.
G2 (P<0.01)
G1 �9.31
(SD �4.47),
G1∗�8.03
(SD �4.28)
G2 �8.58
(SD �4.36),
G2∗�9.48
(SD �4.14) the
total score of
HADS-A
improved: G1 vs.
G2 (P<0.01)
G1 �7.25
(SD �4.05),
G1∗�5.69
(SD �3.46)
G2 �6.48
(SD �3.06),
G2∗�7.39
(SD �3.23)
Evidence-Based Complementary and Alternative Medicine 7

Table 1: Continued.
Authors, year,
country
Main characteristics
of studied
population
Sample
characteristics
(sample size,
mean age)
Sex difference
Intervention
group. vs.
comparison
group
Outcome
measurement tools Outcomes
Mahdavipour
et al., 2019, Iran
Women during their
menopausal period,
aged 40–60 y/o,
diagnosis of
depression by a
psychiatrist based on
DSM-IV, and the
total depression
score >14 based on
the Beck Depression
Inventory
90, G1 �45,
G2 �45 mean age:
G1 �54.18 y/o
(SD �3.90),
G2 �52.23 y/o
(SD �11.6) (10
drop out)
Male: 0
Female: 90
G1 �foot
reflexology
G2 �control
group
Beck Depression
Inventory-second
edition (BDI-II)
e total score of
BDI-II improved:
G1 vs. G2
(P<0.001)
G1 �26.97
(SD �4.47),
G1∗�22.55
(SD �5.18)
G2 �26.15
(SD �5.01),
G2∗�26.22
(SD �5.14)
Soheili et al.,
2017, Iran
Female patients aged
18–75 y/o, with a
definite diagnosis of
multiple sclerosis by
a medicine specialist
75, G1 �25,
G2 �25, G3 �25
mean age:
G1 �34.4 y/o
(SD �6.6),
G2 �33.9 y/o
(SD �5.6)
G3 �34.0 y/o
(SD �7.7)
Male: 0
Female: 75
G1 �foot
reflexology
G2 �relaxation
G3 �control
group
Depression, anxiety
and stress scale-21
(DASS-21)
e total score of
DASS-21
depression
improved: G1 vs.
G3 (P�0.03)
G1 �20.72
(SD �7.56),
G1∗�13.20
(SD �6.16)
G3 �19.52
(SD �6.06),
G3∗�18.64
(SD �6.99) the
total score of
DASS-21 anxiety
improved: G1 vs.
G3 (P�0.03)
G1 �16.72
(SD �6.66),
G1∗�10.40
(SD �7.37)
G3 �16.80
(SD �6.90),
G3∗�14.88
(SD �6.50)
Vardanjani
et al., 2013, Iran
e patients were
candidates for their
first elective
coronary
angiography without
the symptoms of
myocardial
infarction
100, G1 �50,
G2 �50 mean age:
G1 �52.6 y/o
(SD �7.8),
G2 �54.8 y/o
(SD �5.6)
Male: 100
female: 0
G1 �foot
reflexology
G2 �control
group
State-Trait Anxiety
Inventory (STAI)
e total score of
STAI improved:
G1 vs. G2
(P�0.0001)
G1 �53.24
(SD �4.29),
G1∗�45.24
(SD �3.32)
G2 �49.62
(SD �5.31),
G2∗�43.70
(SD �5.06)
8Evidence-Based Complementary and Alternative Medicine

Table 1: Continued.
Authors, year,
country
Main characteristics
of studied
population
Sample
characteristics
(sample size,
mean age)
Sex difference
Intervention
group. vs.
comparison
group
Outcome
measurement tools Outcomes
Bagheri-nesami
et al., 2014, Iran
Voluntary
participants
participate in the
study for first
nonemergency
cardiac surgery by
using a heart-lung
machine
80, G1 �40,
G2 �40 mean age:
G1 �58.75 y/o
(SD �8.69),
G2 �58.90 y/o
(SD �9.58)
Male: 40
female: 40
G1 �foot
reflexology
G2 �control
group
Visual Analogue
Scale of Anxiety
(VAS-A)
e total score of
VAS-A
improved: G1 vs.
G2 (P<0.05)
G1 �1.93
(SD �2.81),
G1∗�1.45
(SD �2.90)
G2 �1.78
(SD �2.11),
G2∗�2.00
(SD �2.44)
Khaledifar
et al., 2017, Iran
Participants aged
≥18 y/o, candidate
for coronary
angiography in
hospital, absence of
acute psychological
disorders, or use of
antistress drugs
within recent
48 hours
75, G1 �25,
G2 �25, G3 �25
mean age:
G1 �67.2 y/o
(SD �11.8),
G2 �67.0 y/o
(SD �11.1)
G3 �64.7 y/o
(SD �12.1)
Male: 38
female: 37
G1 �foot
reflexology
G2 �massage
therapy
G3 �control
group
State-Trait Anxiety
Inventory (STAI)
e total score of
STAI improved:
G1 vs. G3
(P<0.05)
G1 �60.60
(SD �7.20),
G1∗�34.70
(SD �4.70)
G3 �47.80
(SD �9.60),
G3∗�46.50
(SD �9.20)
Saatsaz et al.,
2016, Iran
Female, aged
20–35 y/o, being
primiparous, giving
birth to a living and
healthy child, being
conscious, and
having junior high
school or higher
degree of education
to comprehend the
numerical pain scale
106, G1 �52,
G2 �52, G3 �52
mean age:
G1 �27.04 y/o
(SD �2.77),
G2 �26.73 y/o
(SD �3.81),
G3 �27.75 y/o
(SD �3.22)
Male: 0
Female: 106
G1 �foot
massage
G2 �foot and
hand massage
G3 �control
group
State-Trait Anxiety
Inventory (STAI)
e total score of
STAI improved:
G1 vs. G3
(P<0.05)
G1 �31.52
(SD �9.93),
G1∗�28.23
(SD �8.88)
G3 �30.17
(SD �6.98),
G3∗�30.38
(SD �6.93)
Pasyar et al.,
2018, Iran
Patients who had
undergone tibial
shaft fracture
surgery; aged ≥18 y/
o; an open reduction
and internal fixation
surgery for a tibial
fracture, hospital
admission for at least
1 day after surgery
66, G1 �33,
G2 �33 G1 �not
mentioned
G2 �not
mentioned
Male: 53
female: 13
G1 �foot
reflexology
G2 �control
group
State-Trait Anxiety
Inventory (STAI)
e total score of
STAI improved:
G1 vs. G2
(P<0.05)
G1 �54.72
(SD �7.36),
G1∗�42.84
(SD �6.50)
G2 �57.48
(SD �9.14),
G2∗�58.36
(SD �10.37)
Evidence-Based Complementary and Alternative Medicine 9

Table 1: Continued.
Authors, year,
country
Main characteristics
of studied
population
Sample
characteristics
(sample size,
mean age)
Sex difference
Intervention
group. vs.
comparison
group
Outcome
measurement tools Outcomes
Koras et al.,
2019, Turkey
Patients age ≥18 y/o
who underwent
laparoscopic
cholecystectomy
without any
complication with
pain severity greater
than 4 on VAS
(visual analogue
scale) after surgery
167, G1 �85,
G2 �82 mean age:
G1 �not
mentioned
G2 �not
mentioned
Male: 50
female: 117
G1 �foot
massage
G2 �control
group
State-Trait Anxiety
Inventory (STAI)
e total score of
STAI improved:
G1 vs. G2
(P<0.05)
G1 �49.74
(SD �13.54),
G1∗�28.67
(SD �9.12)
G2 �43.67
(SD �8.11),
G2∗�51.84
(SD �6.61)
Eguchi et al.,
2016, Japan
Men and women
aged 20 to 70 who
lived in or near
Matsuyama, Ehime
Prefecture, Japan
55, G1 �27,
G2 �28 mean age:
G1 �49.0 y/o
(SD �13.6),
G2 �48.8 y/o
(SD �11.4)
Male: 5
female: 50
G1 �foot
reflexology
G2 �control
group
State-Trait Anxiety
Inventory (STAI)
e total score of
STAI improved:
G1 vs. G2
(P<0.05)
G1 �41.1
(SD �11.2),
G1∗�38.0
(SD �9.4)
G2 �40.6
(SD �10.0),
G2∗�40.0
(SD �9.2)
Ozturk et al.,
2018, Turkey
Voluntary
participants who
have undergone
abdominal
hysterectomy
operation and
reported
postoperation pain
of 3 or above
according to visual
analog scale
63, G1 �32,
G2 �31 mean age:
47.23 y/o
(SD �4.71)
Male: 0
female: 63
G1 �foot
reflexology
G2 �control
group
State-Trait Anxiety
Inventory (STAI)
e total score of
STAI improved:
G1 vs. G2
(P<0.05)
G1 �58.87
(SD �4.81),
G1∗�45.75
(SD �4.25)
G2 �57.32
(SD �4.81),
G2∗�55.96
(SD �3.85)
Ramezanibadr
et al. 2018 Iran
Male candidates for
undergoing coronary
angiography, aged
40–80 y/o, had
neither health
problems nor arterial
line in the feet,
received no
anxiolytic agent
during the past
48 hours before the
intervention
150, G1 �50,
G2 �50, G3 �50
mean age: 66.5 y/o
(SD �4.6)
Male: 150
Female: 0
G1 �foot
reflexology
G2 �placebo
group
G3 �control
group
State-Trait Anxiety
Inventory (STAI)
e total score of
STAI improved:
G1 vs. G3
(P<0.05)
G1 �61.68
(SD �—),
G1∗�45.58
(SD �—)
G2 �60.52
(SD �—),
G2∗�59.14
(SD �—)
10 Evidence-Based Complementary and Alternative Medicine

3.4. Efficacy Analysis (Results from Each Meta-Analysis)
Primary Outcomes. e sizes of effect for selected studies
were prominent in depression, anxiety, and sleep distur-
bance. e data revealed in Table 4 that foot reflexology
intervention resulted in significant improvement in adults
with depression, anxiety, and sleep problems.
3.4.1. Depression. Four studies [7, 50, 54, 55] investigated
depression as the primary outcome following foot reflex-
ology intervention by using different depression outcome
measurement tools. ese tools included the Beck De-
pression Inventory Scale; hospital anxiety and depression
scale; and depression, anxiety, and stress scale-21 and were
used in our meta-analysis. Hedges’ gfor the overall effect
size was −0.921, and the 95% CI was −1.246 to −0.595
(Figure 3). e sample collection sizes of effect for sample
collection all came out negative, with Hedges’ granging
from −0.511 to −1.298. Reviewing the results, it is clear that
there was significant reduction in depression following foot
reflexology intervention, with a large effect size. ere was
mean heterogeneity among the studies of depression
(Q�5.42, P�0.143, I
2
�44.74).
3.4.2. Anxiety. e sixteen studies [45–48, 50, 52–62] ex-
amined anxiety as the primary outcome following foot re-
flexology intervention by using different anxiety outcome
measurement tools such as the hospital anxiety and de-
pression scale; depression, anxiety, and stress scale-21; State-
Table 1: Continued.
Authors, year,
country
Main characteristics
of studied
population
Sample
characteristics
(sample size,
mean age)
Sex difference
Intervention
group. vs.
comparison
group
Outcome
measurement tools Outcomes
Shahsavari
et al., 2017, Iran
Patients between the
age of 18–60 y/o, no
lesion or disorder on
the feet and other
conditions affecting
the feet, no previous
history of
bronchoscopy, or
participation in
similar studies
80, G1 �40,
G2 �40 mean age:
G1 �45.55 y/o
(SD �1.78),
G2 �48.23 y/o
(SD �1.72)
Male: 41
female: 39
G1 �foot
reflexology
G2 �control
group
Visual Analogue
Scale of Anxiety
(VAS-A)
e total score of
VAS-A
improved: G1 vs.
G2 (P<0.05)
G1 �4.35
(SD �2.08),
G1∗�2.83
(SD �1.45)
G2 �3.78
(SD �1.83),
G2∗�4.88
(SD �2.15)
Abbaszadeh
et al., 2018, Iran
Participants who had
been diagnosed with
coronary artery
disease and were
candidates for
nonurgent CABG
(coronary artery
bypass graft)
120, G1 �40,
G2 �40, G3 �40
mean age:
G1 �55.90 y/o
(SD �8.31),
G2 �57.32 y/o
(SD �8.62)
G3 �56.30 y/o
(SD �7.11)
Male: 120
female: 0
G1 �foot
reflexology
G2 �placebo
group
G3 �control
group
Short-form of Atate-
Trait Anxiety
Inventory (short-
form of STAI)
e total score of
STAI improved:
G1 vs. G3
(P>0.05)
G1 �8.25
(SD �2.71),
G1∗�6.21
(SD �0.82)
G2 �10.81
(SD �2.16),
G2∗�7.80
(SD �2.31)
Levy et al.,
2020, Israel
Women aged over 18
years, hospitalization
in obstetrics ward
during labor,
primiparity, with
moderate to severe
anxiety at admission
Visual Analogue
Scale (VAS) ≥4
189, G1 �99,
G2 �90 mean age:
G1 �28.6 y/o
(SD �4.4),
G2 �27.9 y/o
(SD �4.5)
Male: 0
female: 189
G1 �foot
reflexology
G2 �control
group
Visual Analogue
Scale of Anxiety
(VAS-A)
e total score of
VAS-A
improved: G1 vs.
G2 (P<0.05)
G1 �7.9
(SD �1.8),
G1∗�5.5
(SD �2.4)
G2 �7.9
(SD �2.0),
G2∗�8.6
(SD �2.4)
BDI-II �Beck Depression Inventory-second edition; CABG �coronary artery bypass graft; DASS-21 �depression, anxiety, and stress scale-21; DSM-
IV �Diagnostic and Statistical Manual of mental disorders, 4
th
edition; G1 �group 1, G2 �group 2, G3 �group 3; HADS-A �hospital anxiety and depression
scale-anxiety; HADS-D �hospital anxiety and depression scale-depression; PSQI �Pittsburgh Sleep Quality Index; SMHSQ �St. Mary’s Hospital Sleep
Questionnaire; STAI �State-Trait Anxiety Inventory; RCSQ �Richard–Campbell Sleep Questionnaire; VAS-A �visual analogue scale for anxiety.
Evidence-Based Complementary and Alternative Medicine 11

Trait Anxiety Inventory; and Visual Analogue Scale of
Anxiety and were included in our meta-analysis. Hedges’ g
for the overall effect size was −1.237, and the 95% CI was
−1.682 to −0.791 (Figure 4). e sample collection effect sizes
all came out negative, with Hedges’ granging from −0.259 to
−3.644. ese results suggested that the overall reduction in
anxiety following foot reflexology intervention was signifi-
cant, with a large effect size. Heterogeneity among the
studies of anxiety was considerably large (Q�217.41,
P<0.001, I
2
�93.10).
3.4.3. Sleep Quality. Hedges’ gof the ten studies
[8, 41–44, 49, 51, 62–64] examined sleep quality following
foot reflexology intervention by using different outcome
measurement tools such as the Pittsburgh Sleep Quailty
Index; the Verran and Snyder-Halpern Sleep Scale; St.
Mary’s Hospital Sleep Questionnaire; and Richard–Camp-
bell Sleep Questionnaire which were included in our meta-
analysis. Hedges’ gfor the overall effect size was −1.665, and
the 95% CI was −2.361 to −0.970 (Figure 5). e effect sizes
for sample collection were unsurprisingly all negative, with
Hedges’ granging from −0.548 to −3.621. e meta-analysis
revealed that the overall improvement in sleep quality fol-
lowing foot reflexology intervention was significant, with a
large effect size. Considerable heterogeneity was observed
among the studies in sleep quality where the outcomes
measured (Q�144.87, P<0.001, I
2
�93.78).
Substantial heterogeneity was found in the anxiety and
sleep quality studies. erefore, subgroup analyses along
with moderator and metaregression analyses were con-
ducted to further explore the determinations of the
heterogeneity.
3.5. Secondary Outcomes (Safety). No adverse events were
reported in the few RCTs on foot reflexology intervention for
depression, anxiety, and sleep quality. Most of the included
studies failed to report this aspect. Dropouts were not treated
as adverse events not only because they were not explicitly
explaining their personal reasons for dropout in the original
study but also because our research material lacked subject
commentary.
3.6. Subgroup Analyses and Metaregression Analyses of
Anxiety and Sleep Quality. Subgroup analyses and metare-
gression analyses to investigate any possible confounding
clinical variables within the studies are presented in Table 5.
3.6.1. Anxiety. Four RCTs revealed evidence for the effects of
foot reflexology when compared with the control group in
reducing the anxiety level before adult undergoing coronary
angiography (Hedges’ g� −1.426, 95% CI was −2.278 to
−0.575, P<0.001). Two RCTs revealed evidence for the
effects of foot reflexology compared with the control group
in reducing the anxiety level for delivering women (Hedges’
g� −0.869, 95% CI was −1.702 to −0.869, P�0.041). Sig-
nificant subgroup differences were identified for the out-
come measures (STAI vs. Others; Hedges’ g� −1.534 vs.
−0.894, P<0.001). Our subgroup analysis performed one
session of foot reflexology intervention, before or after
interventional surgery, which would be more effective than
numerous sessions of foot reflexology intervention, as
according to other interventional surgeries or procedure
studies (one session vs. numerous sessions; Hedges’
g� −1.553 vs. −0.849, P<0.001). Other subgroup analysis
indicated cardiovascular surgery or an interventional pro-
cedure was less effective than other surgery or interventional
procedures (cardiovascular vs. other surgery; Hedges’
g� −1.060 vs. −2.340, P<0.001), which significantly re-
duced the anxiety level of psychological symptoms. e
selection bias including random sequence generation and
allocation concealment of study also showed significant
differences in interactions between subgroups (P<0.05).
In the exploratory metaregression analysis of anxiety, no
significant relationship was observed between the effect size
for mean age (P�0.852) and total length of intervention in
one time period (P�0.903).
3.6.2. Sleep Quality. Subgroup analysis was performed using
the parameters study group and participants type. However,
results of the subgroup analysis indicated that heterogeneity
may have resulted from the abovementioned factors. While
performing the metaregression, the mean age of partici-
pants, duration of intervention sessions, and total foot re-
flexology intervention time were required as possible
moderating variables. e selection bias including random
sequence generation and allocation concealment of study
also showed significant differences in interactions between
subgroups (P<0.05).
Regression analyses revealed a positive correlation with
the total length of foot reflexology intervention time
(P�0.002) and duration of intervention sessions (P�0.01),
indicating that the more the total length of foot reflexology
intervention time and duration of intervention sessions, the
more likely it is to have significant results. However, the
mean age of participants did not report any significant
impact (P�0.897).
4. Discussion
4.1. Summary of Evidence. We analyzed the impact on foot
reflexology on depression, anxiety, and sleep quality. Meta-
analysis for improvement of psychological symptoms in-
dicated that the foot reflexology could effectively relieve
depression, anxiety, and sleep quality. However, effect sizes
of various studies were heterogeneous. In addition, not
only did we focus on the possible moderating clinical
factors but also investigated the possible confounding effect
by the different measurement tools.
Overall, the application of foot reflexology was not
associated with degradation of psychological symptoms or
a rapid increase in adverse effects. Only a few studies
explicitly assessed safety-related, nonserious adverse
events. Foot reflexology is most likely a comparatively safe
practice for this population. However, future RCTs should
take more measures to establish even more accurate
12 Evidence-Based Complementary and Alternative Medicine

Table 2: Characteristics of foot reflexology programs and outcomes assessment of studies included in meta-analysis.
Authors, year
Frequency
(sessions/
week)
Session length
(mins/session)
Duration
(weeks/
study)
Number of
sessions/study
total length/study
Safety
(adverse
events)
Lasting effects
and duration
Adherence
rate (%)
Valizadeh et al.,
2015 1
20 (total 20 min,
10 min for each
foot)
6 6 (2 hours) Not
reported Not reported 23/23 �100%
Li et al., 2011 5
30 (total 30 min,
15 min for each
foot)
1 5 (2.5 hours) Not
reported Not reported 32/34 �94%
Bakir et al., 2018 1
60 (total 60 min,
30 min for each
foot)
6 6 (6 hours) Not
reported Not reported 30/31 �96%
Unal et al., 2016 2
30 (total 30 min,
15 min for each
foot)
4 8 (4 hours) Not
reported Not reported 35/35 �100%
Zengin et al., 2018 2
30 (total 30 min,
15 min for each
foot)
8 16 (8 hours) Not
reported Not reported 84/88 �95%
Rambod et al.,
2019 5
30 (total 30 min,
15 min for each
foot)
1 5 (2.5 hours) No side
effect Not reported 36/36 �100%
Malekshahi et al.,
2018 3
10 (totally
10 min, 5 min for
each foot)
4 12 (2 hours) Not
reported Not reported 40/40 �100%
Oshvandi et al.,
2014 2
20 min (totally
20 min, 10 min
for each foot)
1 2 (0.66 hours) Not
reported Not reported 30/30 �100%
Samarehfekri
et al., 2020 3
30 min (totally
30 min, 15 min
for each foot)
1 3 (1.5 hours) No side
effect
1 week after
intervention 25/26 �96%
Toygar et al., 2020 3
30 min (totally
30 min, 15 min
for each foot)
1 3 (1.5 hours) Not
reported Not reported 33/33 �100%
Bahrami et al.,
2019 1
20 min (totally
20 min, 10 min
for each foot)
1 1 (0.33 hours) No side
effect Not reported 45/45 �100%
Noh et al., 2019 3
30 min (totally
30 min, 15 min
for each foot)
6 18 (9 hours) Not
reported Not reported 32/33 �96%
Mahdavipour
et al., 2019 2
30 min (totally
30 min, 15 min
for each foot)
6 12 (6 hours) Not
reported
2 months after
intervention 45/50 �90%
Soheili et al., 2017 2
40 min (totally
40 min, 20 min
for each foot)
4 8 (5.33 hours) Not
reported Not reported 25/25 �100%
Vardanjani et al.,
2013 1 30 min 1 1 (0.5 hours) Not
reported Not reported 50/50 �100%
Bagheri-nesami
et al., 2014 4
20 min (totally
20 min, 20 min
for left foot)
1 4 (1.33 hours) Not
reported Not reported 40/40 �100%
Khaledifar et al.,
2017 1
30 min (totally
30 min, 15 min
for each foot)
1 1 (0.5 hours) Not
reported Not reported 25/25 �100%
Saatsaz et al., 2016 1 - 1 1 (—) Not
reported
90 min after foot
massage 52/52 �100%
Pasyar et al., 2018 1
10 (total 10 min,
5 min for each
foot)
1 1 (0.16 hours) Not
reported
2 hours after
foot massage 33/33 �100%
Koras et al., 2019 1
40 (total 40 min,
20 min for each
foot)
1 1 (0.66 hour) Not
reported
90 min after foot
massage 85/85 �100%
Eguchi et al., 2016 3 45 min 4 12 (9 hours) No side
effect Not reported 27/27 �100%
Evidence-Based Complementary and Alternative Medicine 13

Table 2: Continued.
Authors, year
Frequency
(sessions/
week)
Session length
(mins/session)
Duration
(weeks/
study)
Number of
sessions/study
total length/study
Safety
(adverse
events)
Lasting effects
and duration
Adherence
rate (%)
Ozturk et al., 2018 3
20 (total 20 min,
10 min for each
foot)
1 3 (1 hour) Not
reported Not reported 32/32 �100%
Ramezanibadr
et al., 2018 1 20 min 1 1 (0.33 hour) Not
reported
1 hour after foot
reflexology 50/50 �100%
Shahsavari et al.,
2017 1 30 min 1 1 (0.5 hour) Not
reported Not reported 40/40 �100%
Abbaszadeh et al.,
2018 4
30 (total 30 min,
15 min for each
foot)
1 4 (2 hours) Not
reported Not reported 40/40 �100%
Levy et al., 2020 1 30 (total 30 min) 1 1 (0.5 hour) No side
effect Not reported 99/99 �100%
Table 3: Risk of the methodological bias score of included studies.
Authors, year
Random
sequence
generation
(selection bias)
Allocation
concealment
(selection bias)
Binding of
participants and
personnel
(performance bias)
Blinding of
outcome
assessment
(detecting bias)
Incomplete
outcome data
(attrition bias)
Selective
reporting bias
(reporting
bias)
Other
bias
Valizadeh, 2015 U U H U L L H
Li, 2011 L U H H L L U
Bakir, 2018 U U U U L L H
Unal, 2016 U U U U L L H
Zengin, 2018 L U U U L L U
Rambod, 2019 L L H L L L U
Malekshahi,
2018 U U U U U L H
Oshvandi, 2014 L L H U L L U
Samarehfekri,
2020 L L U U L L U
Toygar, 2020 L U L L L L U
Bahrami, 2019 L L H U L L U
Noh et al., 2019 L U H U L L U
Mahdavipour
et al., 2019 U U H U L L U
Soheili et al.,
2017 L U H U L L U
Vardanjani et al.,
2013 L U H U L L H
Bagheri-nesami
et al., 2014 L U U U L L U
Khaledifar et al.,
2017 U U U U L L H
Saatsaz et al.,
2016 L U H U L L H
Pasyar et al.,
2018 L L H U L L H
Koras et al., 2019 U U H U L L H
Eguchi et al.,
2016 U U U U L L U
Ozturk et al.,
2018 L U H U L L U
Ramezanibadr
et al., 2018 L U H U L L U
Shahsavari et al.,
2017 L U H U L L U
Abbaszadeh
et al., 2018 L L U L L L U
Levy et al., 2020 L U H L L L U
H: high risk, L: low risk, U: unclear.
14 Evidence-Based Complementary and Alternative Medicine

–4–3–2–101234
0.0
0.1
0.2
0.3
0.4
0.5
Standard error
Hedges’s g
Funnel plot of standard error by hedges’s g
Figure 2: Visual inspection of the funnel plot for effect for improving anxiety symptom.
Table 4: Overall effect size of foot reflexology intervention for an adult.
Effect size 95% CI Null hypothesis Heterogeneity
Two-tailed test
Sample size (studies) Hedge’s gLower Upper Zvalue PValue Qvalue Pvalue I
2
Depression 4 −0.921 −1.246 −0.595 −5.542 <0.001 5.42 0.143 44.74
Anxiety 16 −1.237 −1.682 −0.791 −5.435 <0.001 217.41 <0.001 93.10
Sleep quality 10 −1.665 −2.361 −0.970 −4.692 <0.001 144.87 <0.001 93.78
Pvalues >0.001 were rounded to two digits. CI, confidence interval.
Study name Var ia nc e Z value p value
–1.298 0.230
0.253
0.219
0.296
0.166
0.053
0.064
0.048
0.087
0.028
–0.511
–0.863
–0.992
–0.921
–0.847
–0.015
–0.434
–0.413
–0.595
–5.635
–2.020
–3.945
–3.357
–5.542
–4.00 4.00–2.00
Foot reflexology Control
2.000.00
0.001
0.043
0.001
0.001
0.001
–1.749
–1.007
–1.291
–1.571
–1.246
Bahrami. T., 2019
Noh. G.O., 2019
Mahdavipour. F., 2019
Soheili. M., 2017
Upper
limit
Standard
error
Hedges’s
g
Lower
limit
Statistics for each study
Hedges’s g and 95% CI
Overall effective size of depression (N = 4)
Figure 3: Overall effect size of the improvement of depression in adults following foot reflexology intervention (n�4 studies).
Study name Var i a n ce Z value p value
–1.330 0.231
0.257
0.285
0.201
0.222
0.054
0.066
0.081
0.041
0.049
–0.728
–0.623
–0.482
–0.259
–0.876
–0.224
–0.064
–0.088
0.177
–5.748
–2.832
–2.185
–2.395
–1.163
–4.00 4.00–2.00
Foot reflexology Control
2.000.00
0.001
0.005
0.029
0.017
0.245
–1.783
–1.233
–1.182
–0.877
0.433 0.187–3.315 –2.466 –7.657 0.001–4.163
0.197 0.039–0.436 –0.050 –2.214 0.027–0.822
0.274 0.075–1.457 –0.919 –5.311 0.001–1.995
0.252 0.064–3.644 –3.150 –14.461 0.001–4.138
0.267 0.071–0.265 –0.258 –0.992 0.321–0.789
0.356 0.127–2.862 –2.164 –8.032 0.001–3.560
0.248 0.062–1.415 –0.929 –5.703 0.001–1.901
0.226 0.051–0.554 –0.112 –2.455 0.014–0.997
0.159 0.025–1.286 –0.974 –8.069 0.001–1.599
0.208 0.043–0.895 –0.487 –4.296 0.001–1.303
0.250 0.063–0.678 –0.187 –2.708 0.007–1.169
0.228 0.052–1.237 –0.791 –5.435 0.001–1.682
–0.695
Bahrami. T., 2019
Noh. G.O., 2019
Soheili. M., 2017
Vardanjani. M.M., 2013
Bagheri-Nesami. M., 2014
Khaledifar. A., 2017
Saatsaz. S., 2016
Upper
limit
Standard
error
Hedges’s
g
Lower
limit
Statistics for each study
Hedges’s g and 95% CI
Overall effective size of anxiety (N = 16)
Pasyar. N., 2018
Koras. K., 2019
Eguchi. E.N., 2016
Ozturk. R., 2018
Shahsavari. H., 2017
Abbaszadeh. Y., 2018
Levy. I., 2020
Toygar. I., 2020
Ramezanibadr. F., 2028
Figure 4: Overall effect size of the improvement of anxiety in adults following foot reflexology intervention (n�16 studies).
Evidence-Based Complementary and Alternative Medicine 15

reporting of adverse events and personal reasoning for
dropouts from participants.
4.2. Comparison with Prior Reviews. No systematic review
explicitly focusing on foot reflexology for improving psy-
chological symptoms including depression, anxiety, and
sleep quality was accessible. Ours is the first systematic
review and meta-analysis with 26 RCTs to focus on the
effects of foot reflexology on depression, anxiety, and sleep
quality. We identified there is no direct correlation or ev-
idence on previous meta-analysis reports on self-adminis-
tered foot reflexology with subjective and objective
outcomes for healthy persons [65], benefits of foot reflex-
ology for insomnia [66], or effects of foot reflexology on
fatigue, sleep, and pain [67]. e studies of these analyses are
nonrandomized trials before-and-after studies, and the
sample size of these studies was too small. Future research
should ensure detailed and precise methodology and ade-
quate sample size to better evaluate the impact of foot re-
flexology intervention. Results of previous reviews published
on 2019 reveal effectiveness of reflexology intervention on
premenstrual syndrome [68] and anxiety of patients un-
dergoing cardiovascular interventional procedures [69].
ese two recent reviews illustrated that all reflexology
intervention practices including hand reflexology and foot
reflexology benefited participants in specific groups. Our
meta-analysis with 26 RCTs emphasized foot reflexology
intervention on depression, anxiety, and sleep quality and
conducted further exploration on the determinants of the
heterogeneity with subgroup analysis for both categorical
and continuous moderators to find significant factors for
perceived heterogeneity.
4.3. External and Internal Validity. Major threats to external
validity included specific variables of sampled participants
and multiple foot reflexology intervention types. e ma-
jority of RCTs included participants from Asia. e lack of
studies from America, Europe, and Africa was apparent. It
might not be applicable to other areas. Heterogeneity is high
due to wide variability in participant groups, foot reflexology
technique, selection of reflexology zones, foot reflexology
intervention duration, and frequency.
Internal validity is limited due to the methodological
quality of the included studies. All of the included studies
used self-reported questionnaires for depression, anxiety,
and sleep quality; thus, recall bias could not be excluded. It
remains to be determined whether differences in these
parameters could affect results. All of our studies asserted
that they had applied randomization methods; however, not
all of the studies elaborate on the design protocol and
methods of randomization, and some of the included studies
seem to not have been truly randomized. It also proves
difficult to properly blinding. Only one of the reviewed RCTs
successfully implemented blinding in the participants [62].
Erroneous random sequence generation and allocation
concealment have been empirically revealed to be a sig-
nificant source of bias in RCTs [70]. Our included studies
only had a low risk or an unclear risk of selection bias with
no high risk selection bias. All the effects were robust against
potential risk of selection bias, and the internal validity of the
review, while limited, is still acceptable.
4.4. Strengths and Weaknesses. is is the first and latest
comprehensive systematic review and meta-analysis avail-
able on foot reflexology for depression, anxiety, and sleep
quality with a large number of randomized controlled trials.
None of studies provided any adverse effects of foot re-
flexology, thereby indicating the importance of using foot
reflexology as an effective and less complicated intervention
practice. ere were seven primary limitations of this review
[71]. First, despite great efforts to locate all relevant RCTs of
foot reflexology intervention for psychological symptoms,
there may be a degree of uncertainty due to a limitation in
interlanguage communication, limited resources, and bias in
publication. Due to language constraints, we did not include
Arab States, Japanese, and Korean database. Second, only
one of the studies provided the methods of blinding. Par-
ticipant blinding is sometimes impossible to fully control;
for example, trials in sport, surgical intervention,
Study name Var i a n ce Z value p value
–4.00 4.00–2.00
Foot reflexology Control
2.000.00
0.304 0.092–0.867 –0.272 –2.857 0.004–1.462
0.287 0.082–1.837 –1.275 –6.404 0.001–2.400
0.293 0.086–1.582 –1.007 –5.400 0.001–2.156
0.380 0.144–3.515 –2.771 –9.258 0.001–4.259
0.251 0.063–3.621 –3.129 –14.428 0.001–4.113
0.238 0.056–0.548 –0.082 –2.306 0.021–1.014
0.283 0.080–2.235 –1.679 –7.888 0.001–2.790
0.265 0.070–0.806 –0.286 –3.038 0.002–1.326
0.288 0.083–0.746 –0.181 –2.589 0.010–1.311
0.258 0.067–0.983 –0.478 –3.813 0.001–1.489
0.355 0.126–1.665 –0.970 –4.692 0.001–2.361
Valizadeh. L., 2015
Li. C.Y., 2011
Upper
limit
Standard
error
Hedges’s
g
Lower
limit
Statistics for each study
Hedges’s g and 95% CI
Overall effective size of sleep quality (N = 10)
Bakir. E., 2018
Unai. K.S., 2016
Zengin. L., 2018
Rambod. M., 2019
Samarehfekri. Atena., 2019
Malekshahi. F., 2018
Oshvandi. K., 2014
Toygar. I., 2020
Figure 5: Overall effect size of the improvement of sleep quality in adults following foot reflexology intervention (n�10 studies).
16 Evidence-Based Complementary and Alternative Medicine

nonpharmacological therapy, were all not valued as ap-
propriate, lacking pragmatic and systemic aim. Previous
studies provided empirical evidence of pronounced bias due
to deficiency in patient bias control in related randomized
clinical trials with patient-reported outcomes [72]. ird, the
critical flaw of this study was the relative lack of high-quality
RCTs. e small number of participating studies meant that
the statistical power to detect differences was suboptimal.
Future large-scale trials may be recommended to demon-
strate this effect. Fourth, masseuses often chat with their
clients which has a psychological effect which may influence
this research. Social interaction has been known to reduce
stress and anxiety. If some practitioners speak to their clients
while others do not, this would impact results greatly.
Control over social interaction is needed for further re-
search. e fifth limitation is the severity of the complaints
concerning psychological symptoms and health status of the
participants. is was not considered appropriate and was
not individually listed in each study. Differences in self-
reported questionnaires were found between intervention
and control groups in some studies. is may have led to
heterogeneity. e sixth limitation was that the intensity
(size of strength), frequency (sessions of per week), and
duration (time of each session) of foot reflexology inter-
ventions were all heterogeneous. Most of the studies were
short-term applications without long-term follow-up effects.
Lastly, a lack of priority in safety evaluation may have caused
each study to produce minimal occurrences in serious ad-
verse events or nonserious events. It only can be assumed
that foot reflexology intervention is a low-risk treatment
option.
4.5. Implications for Further Research. If possible, we should
expand research parameters to include western countries
such as Canada or the United States. Different countries
Table 5: Mean effect sizes and moderator analyses of foot reflexology intervention.
Parameter Results Effect sizes (Hedges’ g) 95%CI
Anxiety
Categorical moderators
Outcome measurement tool
STAI 9 −1.534 −2.332, −0.736
Others 7 −0.894 −1.241, −0.547
Reflexology before/after
Surgical intervention
Before 5 −1.409 −2.083, −0.735
After 5 −1.745 −3.066, −0.427
Intervention type
1 time intervention 9 −1.553 −2.190, −0.915
>1 time intervention 6 −0.849 −1.471, −0.226
Surgical intervention type
Cardiovascular intervention 5 −1.060 −1.652, −0.467
Other surgery 5 −2.340 −3.485, −1.195
Random sequence generation
High/unclear risk 3 −2.401 −4.737, −0.064
Low risk 13 −0.970 −1.275, −0.666
Allocation concealment
High/unclear risk 12 −1.271 −1.812, −0.730
Low risk 3 −1.102 −1.668, −0.536
Sleep quality
Outcome measurement tool
PSQI 7 −2.021 −2.931, −1.112
Others 3 −0.853 −1.158, −0.548
Participant −
Hemodialysis group 2 2.850 −4.104, −1.596
Nonhemodialysis group 8 −1.375 −2.119, −0.632
Random sequence generation
High/unclear risk 4 −2.032 −3.033, −1.031
Low risk 6 −1.424 −2.395, −0.454
Allocation concealment
High/unclear risk 7 −2.085 −2.913, −1.257
Low risk 3 −0.686 −0.981, −0.390
Anxiety
Parameter Results Slope 95% CI
Continuous moderators
Mean age 11 −0.155 −1.790, 1.480
Total length in one time 8 −0.126 −2.217, 1.966
Sleep quality
Mean age 8 0.035 −0.049, 0.056
Total length of time 10 −0.346 −0.568, −0.124
Duration 10 −0.256 −0.466, −0.046
Evidence-Based Complementary and Alternative Medicine 17

may include foot reflexology under their national health
insurance or private healthcare plans. If a client has free
access to this treatment, they naturally are more inclined
to continue (adherence rate would increase). However, if
foot reflexology is not covered under a client’s healthcare
provided, they would be less likely to continue (adherence
rate would decrease). is systematic review and meta-
analysis were limited by the low methodological quality of
included studies. Further RCTs should enforce thorough
methodology and reports, which would mean appropriate
sample size, adequate randomization, allocation con-
cealment, intention-to-treat analysis, and bias control of
the least one outcome assessors [73]. In order to achieve
successful bias control of participants and minimize any
physiological effects, a physical force less than the minimal
force is required in foot reflexology at nonreflexology
areas and may be regarded as a sham control. According to
the funnel plots, there could be a publication bias in which
authors lose confidence in their published trials if their
results produced negative conclusions. e quality of the
results of meta-analysis was determined by the quality of
the RCT and by sufficient clinical evidence. us, if we
want to draw a reasonable conclusion for a meta-analysis,
we need larger sample sizes and more rigorously ran-
domized controlled trials. Researchers for study inter-
ventions may need to apply a standard protocol to specific
demographic group. Objective psychological symptoms
measuring tools, such as actigraphy or heart rate vari-
ability analysis, should be incorporated to more accurately
evaluate the effect of foot reflexology. ere is a lack of
evidence in follow-up effects of foot reflexology in psy-
chological symptoms. So, long-term follow-ups should be
necessary in future RCTs. Ample reporting of safety issues
with foot reflexology intervention should be utilized in
future randomized controlled trials. Limited evidence
impaired our research because no studies reported safety-
related adverse effects. Most of the included studies failed
to report on this aspect.
5. Conclusions
Results of this systematic review and meta-analysis
demonstrated that foot reflexology intervention has
benefits compared to nonactive control practices in
terms of ameliorate the burden of depression, anxiety,
and sleep disturbance. Furthermore, metaregression
reveals that an increase in total foot reflexology time
would decrease anxiety and improve sleep quality. De-
spite certain flaws in methodology in our included
studies, foot reflexology may be recommended as a
complementary intervention to improve our depression,
anxiety, and sleep quality. However, advanced strength
of evidence with future understanding of the mecha-
nisms of foot reflexology and long-term follow-up should
be a priority for future preparation and implementation
for sensitive groups, such as delivering women or cancer
patients, who may be unable to use other means of care
and benefit from such care.
Data Availability
e data used to support the findings of this study are in-
cluded within the article.
Conflicts of Interest
e authors declare that they do not have any conflicts of
interest with the conducted research.
Authors’ Contributions
Wei−Li Wang and Ying−Ren Chen conceived and designed
the experiments. Wei−Li Wang, Ying−Ren Chen, Hao-
−Yuan Hung, Yuan−Yu Chan, Kuang−Huei Chen, and
Szu−Nian Yang analyzed the data. Hao−Yuan Hung,
Yuan−Yu Chan, Chi−Ming Chu. Wrote the paper: Wei−Li
Wang, Hao−Yuan Hung, and Yuan−Yu Chan contributed
reagents/materials/analysis tools.
Acknowledgments
e authors acknowledge the grant support from the
Taoyuan Armed Forces General Hospital, Taiwan
(TYAFGH−E−109056). is funding agency did not influ-
ence the study design, data collection and analysis, decision
to publish, or preparation of the manuscript.
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