The House of Lords' Select Committee on Complementary and Alternative Medicine described reflexology as follows:¹

• 'A system of massage of the feet based on the idea that there are invisible zones running vertically through the body, so that each organ has a corresponding location in the foot. It has also been claimed to stimulate blood supply and relieve tension.'

Mechanism of action

The concept behind reflexology is that reflex points on the feet and hands correspond to all of the organs, glands and parts of the body. For example, the toes represent the head and the ball of the foot represents the chest and lung region.² By applying pressure to these points, it is thought that blood circulation is improved, the body relaxes and organs and glands become balanced.²

There is less research on the proposed mechanism of action of reflexology than on acupuncture or manipulation. It is thought that the areas activated by massage of the feet may have something in common with the lines of 'chi' in acupuncture.

Reflexology is thought to be totally safe and can be used in infants and children and pregnant women. A typical session lasts 45-50 minutes and a course of 4-6 once-weekly sessions is usual. It is a complementary therapy and is not meant to replace diagnosis or traditional medicine.

History

Reflexology also used to be known as 'zone therapy'. Therapeutic massage of the feet may have roots in Ancient Egypt and China around 4000 BC.² The concept of zone therapy appears to date back to 1500 AD but a number of books were published about zone therapy in the 16th century. However, it did not gain much popularity until around the turn of the 20th century. Reflexology as we know it today is attributed to the work of Eunice Ingham, an American Therapist who developed its practice in the 1930s and 40s.²

Who uses reflexology?

There has been considerable interest in complementary and alternative medicine with a House of Lords' Select Committee Report in November 2000.¹

In the UK, 47% of people have used complementary and alternative medicine (CAM) at some time in their lives and 10% use some form of CAM each year.³ Users tend to be older, female and over 90% is purchased outside of the NHS. At least 10% of hospital physicians also use CAM as part of their clinical practice but offering reflexology is exceptional.⁴ A survey conducted in 2001 estimated that one in two practices in England now offer their patients some access to CAM.⁵ Of the various forms of CAM, reflexology rates fairly low in terms of popularity and nearly all is obtained outside the NHS.

Evidence for efficacy

Database of Abstracts of Reviews of Effects (DARE)

• DARE discussed a review in 2001 that looked at the existing literature on reflexology.⁶ Seven trials were included in the review, five of which were randomised. However, there were only 214 participants in total so the studies were small and methodologically flawed. The following results were published in the trials:
  • Reflexology of the pituitary-adrenal zones does not alter cortisol levels.
  • Those who had foot reflexology for eight days reported reduced anxiety levels compared to those with no intervention or daily reassurance.
  • Foot reflexology plus conventional care for asthma showed no benefit over conventional care alone.
  • Fewer drugs were given postoperatively in those who had reflexology compared to those who did not. However, there was no statistical analysis in the study.
  • Significantly fewer pre-menstrual symptoms were observed in women receiving ear, hand, and foot reflexology compared with those receiving placebo reflexology for two months.
  • Blood glucose levels and platelet aggregability in patients with type II diabetes were normalised in a group receiving daily foot reflexology for 30 days; no such effects were seen in those receiving no intervention.
  • There was no difference in the intensity and duration of headache in those who had foot reflexology plus oral placebo compared to those who had arm massage plus oral flunarizin at the end of the 2-3 month treatment period.
• The authors of the review concluded that of those trials that have been published on reflexology, 'all are methodologically flawed and their results are non-uniform. The effectiveness of reflexology is not supported by controlled clinical trials.' They suggested that more research was needed to establish specific effects.

Other studies and reviews

• One review showed that 'existing evidence does not indicate a beneficial effect of reflexology in the treatment of hot flushes and other menopausal symptoms.'⁷
• Two recent studies have looked at reflexology for low back pain.^8,9 When reviewed together, the studies suggest that there is a possibility that reflexology may have a treatment specific effect on back pain. However, it is unlikely that reflexology offers treatment advantages over other interventions for the management of chronic low back pain. Further research is needed before any firm conclusions can be drawn.¹⁰
• Another review has stated that 'there is currently a lack of evidence on the effectiveness or otherwise of reflexology in the treatment of anxiety disorders' and suggested that more trials are needed.¹¹
• A further review states that 'there is currently a lack of evidence on the effectiveness or otherwise of reflexology in the treatment of depressive disorders'; again, more rigorous research is recommended.¹²
• The same group looked at the evidence to support the use of reflexology in the treatment of multiple-sclerosis specific symptoms.¹³ They reported that 'the evidence is currently limited as only a small number of studies have been conducted.' However, they suggested that 'evidence from one well-designed randomised controlled trial (RCT) suggests that reflexology may provide improvements for paraesthesia, urinary symptoms and spasticity. Other less well-designed studies point to the need for further RCTs to assess the potential for reflexology to improve pain, bladder control and spasm, and support well-being.'
• Another review looked at reflexology for symptom relief in patients with cancer.¹⁴
• A further systematic review looked at the efficacy of reflexology. It reviewed five studies and concluded that 'there is no evidence for any specific effect of reflexology in any conditions, with the exception of urinary symptoms associated with multiple sclerosis. Routine provision of reflexology is therefore not recommended.'¹⁵

Professional regulation

• The House of Lords' Select Committee was very keen in their report on professional regulation of CAM to set standards for education, registration, behaviour and care.
• At the moment, regulation and registration of reflexologists in the UK is voluntary.
• Patients should be advised to choose a practitioner who holds the letters IIR, MAR. This means that they have graduated from the International Institute of Reflexology and are a Member of the Association of Reflexologists. If they are a member of the Association of Reflexologists, they will have met strict entry criteria and will be insured and hold a First Aid Certificate. They will also be committed to regular post-graduate training to keep their skills up to date.
• There is also a voluntary General Regulatory Council for Complementary Therapies (GRCCT) and the link to their website can be found below. Practitioners on the National Register agree to abide by a Code of Professional Conduct and Ethics, are answerable to the GRCCT Complaints and Disciplinary procedures, maintain their training and knowledge with continuing professional development and have in force professional indemnity and public liability insurance.

Conclusions

• Reflexology is of moderate popularity compared with other CAM treatments.
• It is not possible to give a firm indication of whether it is effective or not because of the quantity and quality of research so far. More trials are needed. However, it should be remembered that lack of evidence for efficacy is not the same as evidence for lack of efficacy.
• Reflexology is unlikely to do any significant harm.