Nursing and Midwifery Research Journal, Vol-8, No.

3, July 2012
223
Effect of 'foot massage and reflexology' on physiological parameters
of critically ill patients
Jasvir Kaur, Sukhpal Kaur, Neerja Bhardwaj
Abstract: 'Foot massage and reflexology' is one of the commonest method of complementary therapies.
Massage therapy and reflexology are manual therapeutic approaches used to facilitate healing, health and can
be used by nurses in almost any setting. The present study was conducted to assess the effect of 'foot
massage and reflexology' on physiological parameters i.e systolic and diastolic blood pressure, heart rate and
oxygen saturation of critically ill patients. The study was carried out in five intensive care units. Using purposive
sampling, 60 patients were enrolled in this study. A protocol on the procedure of 'foot massage and reflexology'
was developed. An Observation checklist was used to record the various parameters. Controlled observations
for all the physiological parameters under study were recorded for the first three days in the morning as well as
in the evening hours with the total of six observations. Then, for the next three days the procedure of 'foot
massage and reflexology' was implemented on the same patients. All the physiological parameters were
recorded just before and after the implementation of protocol on each day in the morning as well as in the
evening hours. Mean age (yrs) SD of study subjects was 46.7 16.1 and 70% were male.During the
controlled observations there was no significant difference in any of the physiological parameters. There was
significant decrease in the systolic blood pressure, increase in diastolic blood pressure, reduction in the heart
rate and improvement in the oxygen saturation in some interventional observations after the intervention. But,
no statistically significant difference was found on the abnormal category of the blood pressure and heart rate.
So, because of the positive results of the intervention, the nurse practitioners may be trained about the
technique of foot massage and reflexology.
Key words :
Physiological parameters, critically ill patients,
foot massage and reflexology.
Correspondence at
Jasvir kaur
V.P.O Partabpura, Teh: Phillaur
Distt: Jalandhar, Punjab
Introduction
Nursing is a profession based on art
and science. This means that a professional
nurse learns to deliver care ar tfully with
compassion. Care should always change with
new discoveries and innovations. When
nurses integrate the science and art of nursing
into their practice, the quality of care provided
to the patients is at a level of excellence that
benefits in innumerable ways.
1
Intensive care
unit(ICU) provides care to patients who are
Nursing and Midwifery Research Journal, Vol-8, No.3, July 2012
224
seriously ill and require 24-hour care and
monitoring.
2
As per Fernandaz et al 13.9% ICU
mor tality rate was due to physiological
parameters alteration.
3
According to the National Center for
Complementary and Alternative Medicine
(NCCAM), complementary therapy is a group
of di verse medi cal and heal th care
systems.
4
Katai found that use of alternative and
compl ementar y medi ci ne i s i ncreasi ng
worldwide. The most frequently used methods
were homeopathy (34.6%) and reflexology
(18.7 %).
5
Touch therapy has always been a part
of the nursing care and now reflexology has
become a par t of this. A nurse researcher
wrote that the foot reflexology is a way to
enhance the nurse-patient interrelationship as
a nurse can easil y and practical l y use
massage. It offers a strategy to fulfill the goals
of human touch and holistic care. It can be
performed at any location, is a non-invasive
and does not i nter fere wi th pati ent' s
privacy.
6
Reflexology is based on the principle
that the hands and feet are mirrors of the body
and they have reflex points that correspond
to each of the body's gland, structure and
organs. It is believed that when a reflex area is
massaged, it stimulates the corresponding
organs in that zone.
7
Massage has mechanical effects that
improve circulation, remove waste products
from the body, improve joint mobility, relieve
pain and reduce muscle tension. It has
psychological benefits such as relaxation and
it improves sense of well-being.
8
A study
showed that foot reflexology is effective in
changing renal blood flow.
9
Labyak and
Metzger evaluated the efficacy of massage and
its effect on the physiological measures of
relaxation. They concluded that the long, slow,
gliding strokes of a massage are associated
with a reduction in heart rate and respiratory
rate.
10
Another study showed the effect of five-
mi nute foot massage on physi ol ogi cal
parameters of the critically ill patients. Results
indicated that foot massage had the potential
effect of increasing relaxation as there were
physiological changes after the intervention
of foot massage.
11
Won and colleagues found
that there was significant difference in systolic
blood pressure, diastolic blood pressure,
pulse rate, general fatigue, and mood status
af ter gi vi ng foot massage. So they
recommended using foot reflexology as an
effective nursing intervention in cancer
patients.
12
Today nursing is focusing on holistic
heal th care and i t i s bel i eved that
complementary therapies are also a part of
holistic nursing. 'Foot massage and foot
reflexology 'helps in improving the circulation
of the blood and assists in relaxation of the
patients. So in this preview, the current study
was conducted to assess the effect of 'foot
massage and reflexology' on physiological
parameters of critically ill patients.
Material and Methods
A quasi experimental research design
was employed. Study was conducted in the
Post Graduate Institute of Medical Education
and Research (PGIMER), Chandi garh.
Nursing and Midwifery Research Journal, Vol-8, No.3, July 2012
225
PGIMER, Chandigarh is a ter tiar y care
hospital, caters to the need of sick and has
about 50,000 annual admissions.It has
various ICUs which are providing care to the
seriously ill patients, main ICU, liver ICU,
respiratory ICU, cardio thoracic ICU and
gastroenterology ICU of Nehru hospital was
sel ected for the current study. Usi ng
purposive sampling technique, patients who
were admitted in above said ICUs during 15
July-31 August 2011 were included in the
study. Patient with foot ulcers and foot fracture
were excluded from the study.60 subjects
were enrolled in this study.Permission was
obtained from the head, Deptt of selected
ICUs, PGIMER, Chandigarh.Informed written
consent was obtained from the patient's
attendants. The study was approved by
Institute Ethical Committee. The tools used for
data collection were sociodemographic and
clinical data sheet, protocol for 'foot massage
and reflexology' technique and an observation
checkl i st to record the physi ol ogi cal
parameters. Tool was prepared by reviewing
the literature and with the help of guide and
co-guide. It was validated by the experts from
the field of nursing education and medicine.
The sociodemographic data sheet
consisted of items like name, age, sex, C.R
no, bed no, ward, date of admission,
diagnosis, educational status, occupation,
total family members, total family income and
per capita income etc. Clinical data consisted
of items such as duration of stay in the
i ntensi ve care uni t, nutri ti on, surger y
performed(if any), level of consciousness,
body built,respiratory devices, physiological
parameters and pharmacological treatment.
'Foot massage and reflexology' protocol
consisted of steps which were followed while
applying the technique.The various steps
followed were sweeping and rubbing, thumb
walking, toe rotation, kneading and cupping.
Data was collected in the month of July
and August 2011. For first three days, the
physiological parameters of each subject were
observed twice a day (morning and evening)
and recorded. For the next three days,
intervention (foot massage and reflexology)
was implemented on the same patients twice
daily(in the morning and evening hours) as
per protocol. All the physiological parameters
i.e the systolic BP, diastolic BP, heart rate,
oxygen saturation were recorded just before
and af ter the i nter venti on by usi ng
Observation checklist.The data was analyzed
as per objectives using both descriptive and
inferential statistics. The effect of foot
massage and reflexology was recorded on
physiological parameters by using various
statistical measures i.e frequency distribution,
measures of central tendency (mean, mode),
measure for dispersion (range, standard
deviation), paired t-test and ANOVA. P values
were considered at 5% and 1% level of
significance.
Results
Sociodemographic data of the subjects
Table 1 shows the socio-demographic
data of the subjects. Mean age (yrs) SD of
the subjects was 46.716.1, with the range
of 16-80 yrs. Around one third (31.6%) were
between 31-45 years. Majority (70%) were
male. 30% were illiterate. 28.3% were self
Nursing and Midwifery Research Journal, Vol-8, No.3, July 2012
226
empl oyed. Around hal f (53.3%) of the
subjects had 1-5 family members in their
families.
Table 1: Socio-demographic data of the
subjects N=60
Variables n(%)
*Age (yrs)
15-30 12(20.0)
31-45 19(31.6)
46-60 16(26.7)
>61 13(21.7)
Sex
Male 42(70.0)
Female 18(30.0)
Educational Status
Illiterate 18(30.0)
Just literate 14(23.3)
Metric 10(16.7)
Senior secondary 06(10.0)
Graduate & above 12(20.0)
Occupation
Student 03(05.0)
Govt.service 07(11.6)
Self employed 17(28.4)
Housewife 13(21.7)
Laborer 04(06.6)
Not working 13(21.7)
Retired 03( 05.0)
**Total family members
1-5 32(53.3)
6-10 26(43.3)
?11 02( 3.4)
*Mean age (yrs) SD:46.716.1, Range: 16-80yrs
**MeanSD:5.412.35, Range: 1-13
Clinical data of the subjects
One four th of the subj ects were
admitted in the main ICU and same number
were admitted in liver ICU. Mean duration
(days) of stay in ICUs was 4.26.96. Majority
(83.3%) had 1-5 days of stay in ICUs. 23%
were on Ryle's tube feeding. As per Glassgow
Coma Scale nearly half (51.7%) of the
subjects were conscious. 53.3% were on
ventilator support and one four th subjects
were on room air without any respiratory
support. Most (71.7%) were having normal
bui l t as per thei r Body Mass
Index (BMI). (Table 2)
Table 2: Clinical data of the subjects
N=60
Variables n(%)
ICU
Main ICU 15(25.0)
Liver ICU 15(25.0)
Respiratory ICU 13(21.7)
Gastroenterology ICU 12(20.0)
Cardiology ICU 05( 8.3)
*Duration of stay in ICU(days)
1-5 50(83.3)
6-10 04(06.7)
11-15 02(03.3)
16-20 01(01.7)
?20 03(05.0)
Type of nutrition
Normal diet 10(16.7)
Diabetic diet 05( 8.3)
Renal diet 10(16.7)
Burn diet 10(16.7)
RT feed** 14(23.3)
Any other*** 11(18.3)
Undergone surgery
Yes 06(10.0)
No 54(90.0)
Level of consciousness
(as per Glassgow Coma Scale)
Unconscious 21(35.0)
Semiconscious 08(13.3)
Conscious 31(51.7)
Body Built
(as per Body Mass Index)
Underweight 07(11.7)
Normal 43(71.7)
Overweight 10(16.6)
Respiratory Device
Ventilator 32(53.3)
T-tube 01( 1.7)
Oxygen 12(20.0)
Room air 15(25.0)
*Mean duration of stay (days) SD:4.26.96, Range:1-37
**Burn+khichri diet, milk, juice ect through Ryle'stube
***Hepatic diet, salt restricted diet, NPO.
Nursing and Midwifery Research Journal, Vol-8, No.3, July 2012
227
During controlled observations, no
significant difference was observed in systolic
BP, diastolic BP, and oxygen saturation. But in
the heart rate, from first to fifth observation,
there was significant increase in the controlled
observation. During the post interventional
observations, in the systolic BP, from the first
obser vation to the four th obser vation,
significant increase was recorded which was
not toward the desire end. Otherwise, there
was fluctuation in the other reading but the
difference was not significant. In diastolic BP,
from the first observation to the third, fourth
and fifth continuous observation fluctuations
were noted.
In the heart rate of subjects, there was
si gni fi cant i ncrease from fi rst to thi rd
obser vati on. But from fi rst to si xth
observation, heart rate was decreased. In
oxygen saturation, the values were same in
the control l ed and post i nter venti onal
observations.(Table 3 & 4)
Table 3: Physiological parameters (mean values) of the subjects during controlled and
post interventional observation N=60
Physiological Observations Mean SD
Parameter 01 02 03 04 05 06
Controlled 118.8 121.8 123.5 123.9 124.2 123.4
Systolic observation 22.6 19.7 22.0 21.9 20.1 20.1
blood Post 122.9 124.8 129.3 130.4 124.8 125.8
pressure Interventional 17.2 19.3 19.2 18.0 20.5 18.0
mm kg observation
Controlled 69.8 71.0 70.7 71.4 73.3 72.5
Diastolic observation 13.3 14.3 17.3 15.8 14.3 12.6
blood Post 73.3 73.1 76.2 75.5 75.9 77.7
pressure Interventional 13.6 12.0 13.3 12.5 15.2 13.2
mmHg observation
Controlled 95.4 99.8 100.5 101.4 100.2 98.4
Hear t observation 19.6 20.4 22.3 22.1 18.3 18.9
rate Post 98.8 96.8 101.0 94.1 98.6 94.5
per minute Interventional 18.7 20.4 20.6 17.1 20.6 16.8
observation
Controlled 97.2 97.7 97.3 97.8 97.2 97.8
Oxygen observation 4.0 3.1 3.7 3.1 3.7 3.2
saturation Post 97.9 98.3 97.5 98.1 96.9 97.8
Interventional 3.0 2.0 2.8 2.0 3.5 2.6
observation
O1=observation 1, o2=observation 2..so on.
Nursing and Midwifery Research Journal, Vol-8, No.3, July 2012
228
Table 4: Difference between Physiological Parameters of the Subjects during Controlled
and Post Interventional Observation
Physiological Observations t, p values
Parameters O1vs O2 O1vsO3 O1vsO4 O1vsO5 O1vsO6
Controlled -0.99, 0.32 -1.35, 0.18 -1.53, 0.13 -1.57, 0.12 -1.36, 0.17
Systolic observation
Blood Post -0.93, 0.35 -1.81, 0.07 -2.34, 0.05* 0.32, 0.97 -2.8, 0.77
Pressure Interventional
mmHg observation
Diastolic Controlled -0.67, 0.50 -0.41, 0.68 -0.73, 0.46 -0.41, 0.68 -0.41, 0.68
Blood observation
Pressure Post 0.15, 0.87 -2.68, 0.05* -3.89,0.001** -2.00, 0.05* -2.74, 0.08
mmHg Interventional
observation
Heart Controlled -0.73, 0.46 -0.73, 0.46 -1.91, 0.06 -2.30, 0.05* -1.89, 0.06
Rate observation
Per Minute Interventional 1.08, 0.28 -0.13, 0.89 3.48, 0.05* 0.76, 0.44 2.72,0.001*
observation
Oxygen Controlled -1.12, 0.26 -1.18, 0.24 -1.18, 0.24 -3.35, 0.73 -1.18, 0.24
Saturation observation
Post -1.23, 0.22 0.16, 0.87 -1.44, 0.15 -1.43, 0.15 -0.53, 0.59
Interventional
observation
*p<0.05, **p<0.01 01 - observation 1, 02 observation.............. go on
The immediate effect of foot massage and
reflexology on the systolic blood pressure was
recorded in the fourth and sixth observation
as there was significant decrease (toward the
normal range) in the systolic BP af ter
inter vention. (t=2.60, 2.24, p<0.05).
Otherwise no significant effect was recorded
in the other observations. The difference in
the diastolic BP, in the second observation
there was significant increase (toward the
normal range) in diastolic BP (t=-2.79,
p<0.01). There was significant reduction
(toward the normal range) in the heart rate in
the first, second, third and fifth observation
after the intervention. (t=2.09, 2.14, 2.29,
4.07, p<0.05). After theintervention, there
was significant improvement in the oxygen
saturation in the second and fifth observation.
(t=-4.21, -3.19, p<0.01) (Table 5& Fig 1)
Nursing and Midwifery Research Journal, Vol-8, No.3, July 2012
229
126.7
125.2
74.6 76.4
98.2 95.8
97.7 98.1
Syarolic BP Diastolic BP Heart Rate Oxygen saturation
Before After
140
120
100
80
60
40
20
0
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Effect of intervention on physiological
parameters (category wise)
The subjects were categorized as per
the normal and abnormal values of the blood
pressure. The subjects with blood pressure
of more than 140/90 mmHg (considered
as hyper tensi ve) and l ess than
90/60mmHg(considered as hypotensive)was
included in the abnormal category. Fisher exact
test did not show any significant difference
(p>0.05). Before the intervention 95% of the
subjects had the normal BP. But after the
intervention, this number increased to 96.7
%.The effect of foot massage and reflexology
was assessed on the normal and subnormal
heart rate. The subjects with heart rate of less
than 60 bpm (considered as bradycardia) and
more than 100 bpm (consi dered as
tachycardia) were included in abnormal
category. Before the intervention 66.7% of the
subjects had normal heart rate. But after the
intervention, this number increased to 70%.
Fig 1: Average Values of Physiological Parameters before and after the Intervention
But, results did not show any statistically
significant difference (p>0.05) (Table 6)
Physiological Before After
parameters
Normal BP
(90/60-140/
90mmHg) 57(95.0) 58(96.7)
Abnormal
BP>140/90or
<90/60 mmHg 3(5.0) 2(3.3)
X
2
, df, p-value 0.21, 1, 1.00
Normal HR
(60-100 bpm) 40(66.7) 42(70)
Abnormal
HR>90or<60 20(33.3) 18(30)
bpm
X
2
, df, p-value 0.26, 1, 0.82
Table 6: Effect of Intervention on
Physiological parameters (Category Wise)
N=60
Nursing and Midwifery Research Journal, Vol-8, No.3, July 2012
230
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Nursing and Midwifery Research Journal, Vol-8, No.3, July 2012
231
there was significant difference in the second
and in the average of six observations.
Diastolic blood pressure was increasing from
first to fifth observation in current study.
Hence showing immediate impact of foot
massage and reflexology on physiological
parameters.
However, Park and Cho (2004) did not
find any significant differences in diastolic
blood pressure and LDL cholesterol level
between the foot reflexology group and the
control group, though, the intervention was
effective in decreasing systolic blood pressure
and triglycerides and in improving the life
satisfaction amongst the patients.
17
The effect of foot massage and
reflexology was noted on the heart rate. There
was reduction in the heart rate as before the
intervention 66.7% were in normal category
and after the intervention it was increased to
70%. There was statistically significant
reduction in the heart rate (toward normal) of
the subjects from the first observation to
fourth and sixth observation. There was also
immediate effect of intervention on heart rate.
Moeini et al showed that the average systolic
and diastolic blood pressure between the two
groups of intervention and control had a
significant difference after conducting the
reflexotherapy. But, for the hear t rate and
respiration rate, the average changes in these
parameters showed no significant statistical
difference between the two groups. However,
the results showed that in intervention group,
the average heart rate and respiratory rate per
minute had slightly decreased af ter the
reflexotherapy.
18
Frankal found that reflexology
Discussion
Reflexotherapy is one of the available
interventions in complementary medicine and
treatment which provides an opportunity for
nurses to care for their patients.
13
Massage
therapy and refl exol ogy are manual
therapeutic approaches used to facilitate
healing and health and can be used by nurses
in almost any setting.
14
Reflxotherapy has
posi ti ve i mpact on the physi ol ogi cal
parameters, so in comparison of these
studies, to see the effect of foot massage and
reflexology on physiological parameters i.e
systolic blood pressure, diastolic blood
pressure, heart rate and oxygen saturation,
current study was conducted in the ICUs of
Nehru Hospital, PGIMER, Chandigarh.
As one study suggested that a foot
reflexology massage could be utilized as an
effective nursing intervention to reduce
depressi on, stress responses and to
strengthen immune systems in middle-aged
women. There was a statistically significant
difference in depression, perceived stress,
systolic blood pressure, natural-killer cells and
IgG af ter foot massage.
15
Quattrin et al
conducted a study on the anxiety level of the
cancer patients and effect on their vital signs
such as systolic blood pressure, diastolic
blood pressure, heart rate and respiratory rate
with reflexology. These were significantly
decreased in vital signs after 30 minutes of
reflexology.
16
In the current study,there was
decrease in the systolic blood pressure toward
the normal range as there was statistically
significant decrease in the four th and fifth
observation. In the diastolic blood pressure
Nursing and Midwifery Research Journal, Vol-8, No.3, July 2012
232
and foot massage group showed significantly
greater reduction in baroreceptor reflex
sensitivity as compared to control group. The
frequency of sinus arrhythmia after reflexology
and foot massage was increased by 43.9%
and 34.1% respectively.
19
In the current study, the effect of foot
massage and reflexology was also assessed
on the oxygen saturation level. In the second,
third and average observation there was a
statistically significant improvement in oxygen
saturation level. Hayes and Cox used mean
ar terial blood pressure as an indicator of
measurement of physi ol ogi cal and
psychological stress in 25 patients in a critical
care unit. They found that there was a
significant decrease in heart rate, mean arterial
blood pressure and respirations during the
foot massage intervention as compared to
those in the control group who received no
i nter venti on. However, there was no
significant effect on peripheral oxygen
saturation.
11
The findings of the study revealed that
there was immediate effect of foot massage
and reflexology on the systolic and diastolic
blood pressure, hear t rate and oxygen
saturation level. But with the comparison of
first six controlled observation and post
interventional observations, no long term
effect of inter vention was recorded on
physi ol ogi cal parameters. So, Nurse
practitioners can be trained in the use of the
foot massage and reflexology to provide
immediate relief to the patients. For assessing
long term effects, it is recommended to take
up another long term study by controlling
more variables.
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