Med. J. Cairo Univ., Vol. 79, No. 2, September: 193-202, 2011 www.medicaljournalofcairouniversity.com Effect of Nursing Interventions Using Foot Reflexology on Blood Pressure and Quality of Life of Hypertensive Patients at Mansoura University Hospitals: Preliminary Results ! ! ! KARIMA ELSHAMY, D.N.Sc.* and EMAN ELSAFETY, M.D.** The Departments Adult Nursing* and Cardiovascular Medical**, Faculty of Nursing, Mansoura University, Egypt Abstract defined as a condition in which individuals have a systolic pressure of equal to or greater than 140mmHg and a diastolic pressure of equal to or greater than 90 mmHg on at least three occasions, or individuals who require medication to remain normotensive [3-5] . ! The aim of this study was to investigate the effect of foot reflexology on blood pressure and quality of life among hypertensive patients. A quasi-experimental study was conducted for patients with hypertension attended the outpatient clinic of the Specialized Medical Hospital at Mansoura University, Egypt, enrolled in this study during six months, between 15 May and 14 October 2010 were randomly allocated into two equal groups (40 in the foot reflexology group (intervention), and 40 in the control group. Hypertension is one of the conditions purported to be improved by complementary therapies such as foot reflexology [1,2] . Pressure techniques applied on the feet are believed to help unblock nerve supply and improve blood flow, which may help the body to function at its peak 1. It is claimed that reflexology relieves stress and tension by inducing relaxation [1,6] . By doing this, it brings about vasodilatation, blood pressure, improved blood flow and provision of oxygen-rich nutrients to cells [1,7,8] . Some authors suggest that 70 to 80% of all diseases and illnesses come from stress including hypertension, migraine, headaches, the common cold, ulcers and coronary heart disease [1,9] . Two tools were used for data collection: I : Demographic and medical interview schedule. II: Quality of Life Questionnaire. Systolic blood pressure decreased significantly in intervention group from 160.2mmHg to 136.5mmHg compared to (162.5mmHg to 155.2mmHg) in controls. There was a statistically significant decrease in means of diastolic blood pressure between pre and post intervention (102.0mmHg –87.5mmHg) within the intervention group ( p<0.05), Change in control group was not proved to be statistically significant (100.1mmHg –96.4mmHg pre and post readings respectively, p>0.05). There was no evidence for improvement in Quality of Life in either group (pre levels was 42.2, 47.1 and post levels was 45.9, 47.4 in the 2 groups respectively). This study supported that foot reflexology can reduce blood pressure levels in patients with hypertension, it did not support that foot reflexology could improve quality of life in these patients. Future research is needed to support these findings specially the negative ones. It is recommended that qualitative research might be used in combination with quantitative research to determine details of patients' feelings, interactions, attitudes, cultural influences and satisfaction after intervention. Although not yet widely used, relaxation techniques are potentially valuable nonpharmacological treatments to lower blood pressure. Such techniques include progressive muscle relaxation, etc ...  . Complementary therapies such as massage and reflexology are claimed to help reduce symptoms of stress and tension resulting in a decrease in blood pressure, and an adjustment of body, mind and spirit to a state of harmony  ; they can also help improve quality of life  . Key Words: Nursing Intervention – Foot reflexology – Hypertension – Blood pressure – Quality of life. Introduction ! HYPERTENSION is one of the conditions purported to be improved by complementary therapies such as foot reflexology [1,2] . Hypertension is Reflexology is believed to be used for more than 4,500 years in Egypt, as pictograph evidence was found in the tomb of an Egyptian physician; some claim that it originated in India and China [2,6] . During intervention, the therapist inserted pressure on reflexology areas of plantar surface of Correspondence to: Dr. Karima Elshamy, Adult Nursing Department, Faculty of Nursing, Mansoura University, Email: [email protected] 193 194 Effect of Nursing Interventions Using Foot Reflexology on Blood Pressure the feet or palm of the hands using his fingers (specially the thumbs) which were related to each part of the body. This caused health restore and had made a balance throughout the body [13,14] . the disease and any treatment side effects but may also, be worried and frustrated about their disease, may be open to complementary therapies as an adjunct to conventional treatments. Reflexology, as a comprehensive approach and a nursing intervention that supports traditional care; can be used in the medical treatments [15,16] . Many studies have investigated reflexology as a noninvasive and non-pharmacological nursing intervention in its various aspects such as: The impact of reflexology on hypotension without any known reasons, reducing triglyceride and blood sugar, improving nausea and vomiting in cancer patients undergoing chemotherapy, reducing depression and improving immune system function, improving pain and anxiety of the cancer patients and decrease the fatigue in pregnant women  . However, in a pilot (small) study conducted on the anxiety of patients before and after the coronary artery bypass graft surgery, this method has a significant effect on the physiological parameters of the patients  . The aim of this study was to: Investigate the effect of foot reflexology on decreasing blood pressure and the improvement in mean quality of life among hypertensive patients. It has been found that health care professionals have increased their use of complementary therapies to help relieve uncomfortable symptoms and suffering of patients with chronic diseases  . Foot reflexology is a well known complementary therapy which claims to help the body achieve homeostasis. It is believed that pressing specific areas on the feet related to specific glands or organs of the body can help these glands and organs to function at their peak, allowing the body to heal itself [1,2] . The principal difference between massage and touch and foot reflexology is that foot reflexology provides not only the relaxation effect obtained from massage or touch but is said to also improve body immunity contributing to healing process [1,2] . Foot reflexology has been scientifically researched in many studies to explore the claimed benefits [19,20] . Some studies have supported its ability to reduce anxiety and pain [21-23] . However, there has been little scientific evidence to support the claim that foot reflexology can reduce blood pressure and serum lipids, and can improve the quality of life in patients with hypertension  . The purpose of this study was to begin to fill this gap by investigating the influence of foot reflexology on blood pressure, serum lipids and quality of life in hypertensive patients. The role of nursing staff is to care for patients as a whole, encompassing body, mind and spirit  . Demonstrating concern for patients’ needs helps to achieve holistic care  . Patients with a chronic disease, who are suffering not only from Hypotheses: 1- There will be a decrease in mean blood pressure level in foot reflexology group (intervention) relative to the control group (no intervention) by the end of four weeks of implementation. 2- There will be an improvement in mean quality of life scores in foot reflexology group (intervention) relative to the control group (routine management) by the end of four weeks of implementation. Subjects and Methods ! Research design: A quasi-experimental, prospective study was conducted for patients with hypertension enrolled in this study. Two groups were studied; foot reflexology group (intervention) and control group (routine management). All patients continued their usual medical treatment throughout the duration of the study. Subjects and setting: The subjects of this study consisted of 80 consecutive eligible patients with hypertension who attended the outpatient clinic of the Specialized Medical Hospital at Mansoura University, Egypt; Subjects were matched and similar in gender, age, educational background, economic factors, marital status, duration of hypertension, medical history and treatments, lifestyle characteristics, and co-morbidities. Patients were randomly allocated and divided to equal numbers. into 40 patients in intervention and control group. Data collection was undertaken during six months, between May and October 2010. Subjects were eligible for inclusion in the study if they were: Adult males and females, aged 18 years and above, had hypertension (systolic blood pressure greater than or equal to 140mmHg, and diastolic blood pressure greater than or equal to 90mmHg) with or without hyperlipidaemia, had two feet, gave informed consent to be involved in the study and fully conscious. Subjects were excluded from the study if they had thrombotic disease of the lower extremities, foot ulcers, foot infections/diseases, or had undergone foot surgery, and pregnant women were excluded. Other criteria of exclusion were: recent major surgery such as open heart surgery, Karima Elshamy & Eman Elsafety lesions or fractures in foot, sprains or bruises of the lower extremities, hemorrhage, epilepsy, diabetic foot complication, thrombosis, kidney stone or gallbladder, irregular heart rate and hypotension [26,27] . Patients with open skin wounds on their feet, a foot tumor or foot metastasis, or radiation treatment to the feet was also excluded  . Tools of the study: Two tools were used in the study: Tool I: Demographic and medical interview schedule: A demographic data questionnaire was written in Arabic language, This tool was developed by Soliman H. (2007) in a pervious study which included questions on gender, age, marital status, educational background, economic factors (specifically, whether patients had financial problems), duration of hypertension, medical history and treatments, co-morbidities, and top medical treatments. It also included questions about lifestyle modification such as fat/salty foods intake, exercise, smoking, alcohol intake, recreation and relaxation. This questionnaire was completed by participants at the first day of the study  . Tool II: Quality of life questionnaire: The World Health Organization Quality of LifeBREF, Arabic version (WHOQOL-BREF) questionnaire was used. The WHOQOL-BREF is a 26item, self-administered, generic questionnaire that is a short version of the WHOQOL-100 scale. The response options range from 1 (very dissatisfied/ very poor) to 5 (very satisfied/very good). It consists of domains and facets (or sub-domains). The items on “overall rating of QOL” (OQOL) and subjective satisfaction with health constitute the general facet on OQOL and health. The more popular model for interpreting the scores has four domains, namely, physical health (seven items), psychological health (six items), social relations (three items) and environment (eight items). Participants completed this questionnaire at the start of the study and following four weeks of intervention  . Methods: Official permission to conduct the study was taken from the hospital responsible authorities after explaining study’s aims. Content validity: The content validity of the first tool along with the including and excluding criteria was submitted to 10 experts in the field of medical surgical nursing, medicine and physiotherapy for their opinion on the items in the tool and the criteria. There was complete agreement by 195 experts and minimal modifications were made based on the given suggestion. Reliability of the tool: A new standardized sphygmomanometer and stethoscope were used to check the blood pressure. The reliability of the sphygmomanometer and stethoscope were checked with other standardized sphygmomanometer and stethoscope. The readings were matched with the comparative devices used for the reliability testing. Pilot study: A pilot study was conducted in the previously mentioned setting, from 5 May 2010 to 10 May 2010. The investigator obtained formal permission from the concerned authority prior to the study. The study was conducted on 10 hypertensive patients who fulfilled the inclusion criteria for the selection of the sample. The purpose of the study was explained to the subjects and consents were obtained after assuring privacy and confidentiality. Baseline information was collected; and blood pressure was checked after intervention. The tools were found feasible and practical. No further changes were made in the tool after the pilot study and the investigator proceeded for the main study. Before taking part in the study, all potential participants were provided with information about the study topic; the study objectives, study methodology, potential risks, and treatment benefits, privacy and confidentiality were assured. Patients who accepted to participate were assured that their participation was entirely voluntary and informed of their rights as research subjects. The investigator clarified this information verbally and provided further details upon request. Patients who wished to participate in the study were asked to give consent to confirm their willingness to be involved in the study. They were also informed that they could withdraw from the study at any time without any impact on their treatment. Prior to randomization, participants were asked to complete a demographic data questionnaire and the World Health Organization Quality of LifeBREF (WHO QOL BREF) questionnaire. Revision of their laboratory data for: A blood sugar, kidney function, lipids and gout. Electrocardiogram was also done for all participants in the study to exclude patients with irregular heart rate. Eligible participants were randomly allocated into two equal groups 40 participants in the foot reflexology group (intervention) and 40 in the control group (routine management). Immediately prior to each treatment session, patients were provided with 10-minute rest. Following this rest time, their blood pressure level was measured by 196 Effect of Nursing Interventions Using Foot Reflexology on Blood Pressure trained nurses in the outpatient clinic using a standard mercury sphygmomanometer and stethoscope before and after each treatment. The researchers worked to decrease factors affecting blood pressure such as emotion, exercise, respiration, meals, tobacco, alcohol, temperature, pain, bladder distension based on the protocols for taking blood pressure  . The sphygmomanometer was calibrated before use. The process of reflexotherapy was explained to the intervention group. Participants in the foot reflexology group received their usual medical treatment and a 30-minute foot reflexology treatment (15m for each foot) twice a week for four weeks. Participants in the control group received their routine usual medical treatment which included physical examination of feet. The research assistant conducted the reflexotherapy; first of all, the relaxation technique was used from the footstalk toward the sole (plantar surfaces) at the beginning of the session. Then, four major plantar reflexology points (solar plexus, pituitary, heart and liver) were put under pressure using the thumbs. The other reflexology areas of the plantar surface of the foot were also massaged and finally intervention was put to an end with massaging the solar plexus by the researcher. At the end of the study (4 weeks), immediately after the intervention, blood pressure level was measured again by the by the research assistant in the clinic. Participants were asked to complete the WHO QOL-BREF again. After data collection, patients in the control group received the same foot reflexology to avoid depriving them from a potentially valuable technique. lumbar, sacral-coccyx zone. 7. Spinal stretch and metatarsal knead  . Working the lungs: 1. Diaphragm relaxer then toe walks from medial metatarsal upwards from diaphragm to base of toes. 2. Do five plantar zones in between metatarsals; repeat other hand, back to start metatarsal knead. 3. Finger walk dorsal five zones in between metatarsals with thumb in fist medial to lateral. 4. Change hands, repeat lateral to medial. Working the toes: 1. Toe walk sideways over throat-thyroid reflex both ways. 2. Finger walk cervical while stretching toe with holding fingers. 3. Toe walk down large toe plantar side latched onto fingers, work medial to lateral. All toes latched onto fingers, work medial to lateral all toes to their roots. 4. Repeat other coming back to start (use other hand). 5. Hook in and back up on pituitary with medial thumb. 6. Working the brain. 7. Toe walk the ridge (eye and ear reflexes) both ways using lateral aspect or edge of thumbs pulling down padding. 8. Side to side relaxer. 9. Metatarsal kneads  . Working the digestive system: 1. Toe walk waistline to diaphragm, cross hatch in both direction with foot in dorsiflexion. 2. Wring out with thumbs. 3. Toe walk waistline to heel line, cross hatch in both directions with foot in dorsiflexion and wring out with thumb. 4. Work the adrenal gland. 5. Work the ileocecal valve reflex hook in and back up right foot. 6. If on left foot cross hatch plantar heel zone working the sigmoid flexor three ways with thumb then hook in and back up. 7. Side to side relaxer  . Relaxing techniques: 1. Ankle stretch ‘under’. 2. Ankle stretch ‘over’. 3. Ankle loosening. 4. Side to side. 5. Spinal stretch. 6. Metatarsal knead. 7. Diaphragm relaxer. 8. Toe rotation  . Working the lateral and medial heel areas: 1. Finger walk lateral hip, knee, leg reflex zone. 2. Change hands and finger walk same reflex from dorsal side to plantar side. 3. Finger walk hip, sciatic reflex around external malleolus. 4. Change hands and finger walk same reflex going opposite direction underneath. 5. Change hands pin point with index finger rotate clockwise on lateral reproductive reflex. 6. Ankle loosening. 7. Dorsiflex foot, toe walk medial Achilles tendon three times. 8. Reflex rotate using thumb as a fulcrum on medial reproductive reflex. 9. Ankle loosening. 10. Finger walk across ankle medial to lateral and lateral to medial. 11. Finish with full range of relaxing techniques  . Working the spine: 1. Toe walk up sacral-coccyx zone. 2. Toe walk up lumbar zone. 3. Toe walk up thoracic zone. 4. Finger walk up cervical zone. 5. Toe walk down thoracic zone. 6. Toe walk down Statistical methods: Random number tables were used to allocate consecutive eligible patients to either group. Foot reflexology procedure: Prior to the study the investigator underwent 2-hours training on foot massage under an expert in the Physiotherapy Department of Faculty of Medicine, Mansoura University. The researcher follows Farnsworth’s method; the researcher starts at the right foot as follows: Karima Elshamy & Eman Elsafety Descriptive statistics included numbers and percentages for qualitative variables and means and standard deviations for quantitative variables. Comparison of means was achieved using 2-tail ttest for independent samples. Chi-square test was used to compare percentages. The threshold of significance was fixed at the 5% level [33,34] . Results ! Demographic characteristics of participants: For this study, the 80 participants were randomly allocated into two groups: (40 in the foot reflexology group (intervention), and 40 in the control group (routine management). Demographic data for the participants was collected and then analyzed for gender, age, marital status, educational background, economic factors, duration of hypertension, medical history, period of treatment for hypertension, and co-morbidities. Lifestyle data such as fat/salty foods intake, smoking, alcohol intake, exercise and recreation / relaxation was also determined. The data is presented in Tables (1-6). Demographic data of control and intervention groups were similar without statistically significant differences in gender, age, educational background, economic factors, lifestyle characteristics, comorbidities and medical treatments, marital status, the length of time experiencing hypertension and the length of time having treatment for hypertension. Demographic characteristics of the studied groups (n=80): Most of patients were married in foot reflexology and control group (77.5%) and (75.0%). Both groups reported achieving similar levels of university education 53.7% and 52.5% of in the foot reflexology group and control group respectively. The majority of participants in both groups had financial problems – 90.0% in the foot reflexology group, 87.5% in the control group. There was no difference between the groups in the length of time that participants had been diagnosed with hypertension, and the duration having treatment for hypertension (Table 1). Lifestyle characteristics of the studied groups (n=80): Almost more than 70% of participants in the two groups ate fat/salty foods more than 16/wk – 82.5 % in the foot reflexology group, 85.0% in the control group. Most participants did not smoke – 55.0% and 55.0% in the foot reflexology and control groups respectively. The majority of participants did not drink alcohol at all – 98.0% in the foot reflexology group and 99.0% in the 197 control group. These results may be related to Egyptian culture and religion. Most of participants (67.5%) in the foot reflexology group and 70.0% of participants in the control group had a sedentary lifestyle, exercising less than once a week. More than 80% of participants in each group had recreation or relaxation time more than once a week 90.0% in the foot reflexology group, 87.5% in the control group (Table 2). Top six co-morbidities of the two study groups: There was no difference in both groups related to the top six co-morbidities and also other comorbidities. Some participants had more than one of co-morbidity, thus the total does not equal 100%. The most co morbid was diabetes 75.0% and 72.5 (Table 3). Table (1): Demographic and clinical characteristics of the studied groups N=80. Characteristic Foot Control Reflexology Group N=40 Group N=40 (Routine (Intervention ) management) N % N % Gender: Male Female 27 13 67.5 32.5 26 14 65.0 35.0 Age/year: 30-40 years 40-50 years 51-60 years 10 12 19 25.0 30.0 47.5 10 12 18 25.0 30.0 45.0 4 31 5 10.0 77.5 12.5 5 30 5 12.5 75.0 12.5 Level of education: No education Primary school Secondary school College/university 5 1 13 22 12.5 2.5 32.5 55.0 5 2 13 21 12.5 5.0 32.5 52.5 Economic/financial difficulties: Yes No 36 4 90.0 10.0 35 5 87.5 12.5 Duration of hypertension/ year: 1-5 years 6-10 years 10-15 years More 15 years 20 10 3 8 50.0 25.0 7.5 20.0 21 9 3 7 52.5 22.5 7.5 17.5 Treatment of hypertension/ year: 1-5 years 6-10 years 10-15 years More 15 years 19 11 5 5 47.5 27.5 12.5 12.5 18 12 4 6 45.0 30.0 10.0 15.0 Marital status: Single Married Divorced/separated/ widowed 198 Effect of Nursing Interventions Using Foot Reflexology on Blood Pressure Table (2): Lifestyle characteristics of the studied groups N=80. Foot Reflexology Group N=40 (Intervention ) Characteristic Control Group N=40 (Routine management) N % N % Fat/salty foods intake: Never <1/wk 1-6/wk Daily 0 2 33 5 0.0 5.0 82.5 12.5 0 0 34 6 0.0 0.0 85.0 15.0 Smoking: Yes No 18 22 45.0 55.0 18 22 45.0 55.0 Alcohol intake: Never <1/wk 1-6/wk Daily 38 2 0 0 95.0 5.0 0.0 0.0 39 1 0 0 97.0 2.5 0.0 0.0 Exercise: Never <1/wk 1-6/wk Daily 27 5 6 2 67.5 12.5 15.0 5.0 28 5 6 1 70.0 12.5 15.0 2.5 Recreation/relaxation: Never <1/wk 1-6/wk Daily 1 36 3 0 2.5 90.0 7.5 0.0 1 35 4 0 2.5 87.5 10.0 0.0 Table (3): Top six co-morbidities of the studied groups N=80. Characteristic Foot Reflexology Group N=40 (Intervention ) Control Group N=40 (Routine management) N % N % Dyslipidaemia 25 62.5 25 62.5 Diabetes Mellitus 30 75.0 29 72.5 Heart Disease 7 17.5 6 15.5 Gout 11 27.5 12 30.0 Kidney 4 10.0 4 10.0 Stroke 2 5.0 3 7.5 Top ten medical treatments of the two study groups: There was no difference in both groups related to the top ten medical treatments and also other treatments. Some participants had more than one medical treatment, thus the total did not equal 100% (Table 4). Results of blood pressure and the quality of life: There was a statistically significant decrease in means of systolic blood pressure between pre and post intervention (160.2mmHg versus 136.5 mmHg) within the intervention group respectively (p<0.05). Change in control group was not proved to be statistically significant (162.5mmHg-155.2 mmHg pre and post readings respectively) ( p>0.05). There was a statistically significant decrease in means of diastolic blood pressure between pre and post intervention (102.0mmHg versus 87.5 mmHg) within the intervention group (p<0.05), Change in control group was not proved to be statistically significant (100.1mmHg versus 96.4 mmHg pre and post readings respectively, p>0.05). There was a little difference in means of quality of life scores between groups before treatment. Differences was not proved to be statistically significant (p>0.05). Mean of quality of life and health satisfaction scores were slightly higher for participants in the foot reflexology group than for participants in the control group. Mean of physical health, psychological health, social relationships and environment scores for participants in the control group were slightly higher than for participants in the foot reflexology group. Quality of life scores pre-post intervention was neither statistically nor clinically significant. Differences were not proved to be statistically significant (p>0.05). There was a significant increase in all patients comments before and after intervention in the foot reflexology group, (75.0%) of patients in the foot reflexology group feel satisfied after the intervention, compared to (52.5%) before intervention. Patients comments indicated that they felt comfortable, relaxed, and believed that treatment could relieve fatigue, numbness and cramps in their feet. p<0.05. Regarding the control group, all patients 'comments before and after routine care indicated no significant differences p>0.05 (Table 6). Post intervention results: There was a decrease in systolic blood pressure of 23.7mmHg in the reflexology group compared with a decrease of 7.3mmHg in the control group. There was a decrease in diastolic blood pressure of 14.5mmHg in the reflexology group compared with a decrease of 3.7mmHg in the control group (Table 5). The findings showed that foot reflexology lower blood pressure in patients with hypertension, but it had little impact on the quality of life in these patients (Table 5). Karima Elshamy & Eman Elsafety 199 Table (4): Top ten medical treatments of the studied groups N=80. Foot Reflexology Group N=40 (Intervention ) Medical treatments Antihyperlypidaemic agents Beta-blockers ACE inhibitors Diuretics Anticoagulants, antithrombolytics & fibrinolytics Anti-anginal drugs Antidiabetic drugs Angiotensin II antagonists Calcium antagonists Other antihypertensive Control Group N=40 (Routine management) N % N % 25 16 15 15 14 62.5 40.5 37.5 37.5 35.0 24 19 13 16 11 60.0 47.5 32.5 40.5 27.5 10 10 5 5 2 25.0 25.0 12.5 12.5 5.0 10 9 6 6 3 25.0 22.5 15.0 15.0 7.5 Table (5): Pre and Post intervention results of blood pressure and the quality of life of the studied groups N=80. Foot Reflexology Group N=40 (Intervention ) Pre intervention Control Group N=40 (Routine management) Post interventions Mean SD Mean SD Systolic blood pressure Diastolic blood pressure 160.2 102.0 2.6 1.2 136.5 87.5 2.0 1.1 Quality of life: Quality of life general score Health satisfaction Physical health Psychological health Social relationships Environment 3.8 3.3 64.3 65.8 70.1 66.2 0.1 0.1 1.7 1.8 1.8 1.5 3.9 3.4 65.0 66.7 70.1 66.5 0.1 0.1 1.3 1.6 1.7 1.5 p-value p<0.05 p>0.05 p>0.05 Pre intervention Post interventions Mean SD Mean SD 162.5 100.1 2.5 1.2 155.2 96.4 2.4 1.2 3.6 3.1 66.1 67.1 75.0 67.8 0.1 0.1 1.6 1.9 2.1 1.9 3.7 3.3 66.0 68.9 74.3 68.0 0.1 0.1 1.5 1.9 2.2 1.8 p-value p>0.05 p>0.05 p>0.05 Table (6): Patients' comments of pre and post intervention of the two groups N=80. Foot Reflexology Group N=40 (Intervention ) Satisfaction: Satisfied Average Not satisfied Feel comfortable Feel relaxed Relieves fatigue, numbness, cramps Control Group N=40 (Routine management) Pre intervention Post interventions N % N % N % N % 21 4 15 52.5 10.0 37.5 30 10 4 75.0 25.0 10.0 19 6 15 47.5 15.0 37.5 15 4 14 37.5 10.0 35.0 10 10 5 25.0 25.0 12.5 19 18 11 47.5 45.0 27.5 8 9 6 20.0 22.5 15.0 8 10 8 20.0 25.0 20.0 p-value p<0.05 Pre intervention Post interventions p-value p>0.05 200 Effect of Nursing Interventions Using Foot Reflexology on Blood Pressure Discussion ! Hypothesis one: There is a decrease in mean blood pressure level between the foot reflexology and control groups at the end of four weeks of treatment. Analyses of data in this study indicated that there was a statistically significant difference in mean blood pressure between the foot reflexology group and control group at the end of four weeks of treatment. The mean diastolic blood pressure in the foot reflexology group was statistically significantly lower than in the control group (p<0.05). Frankel  explored the effects of foot reflexology on the baroreceptor reflex, which controls blood pressure. He found that baroreceptor reflex sensitivity was significantly lowered in the intervention groups (foot reflexology and foot massage), compared with the control group. Baroreceptor reflex sensitivity was measured using sinus arrhythmia and phase IV of the Valsalva maneuver, a period in the Valsalva maneuver during which blood pressure is substantially raised above the baseline. These blood pressure results are different to those outlined by Frankel  who found that, between foot reflexology and foot massage, there was no significant difference in resting blood pressure after intervention. The results of our study supported the hypothesis that foot reflexology decreases blood pressure in patients with hypertension. In this study, the results in relation to blood pressure are comparable to those of Park and Cho  who found in their research that there were no significant differences in diastolic blood pressure and LDL cholesterol between the foot reflexology group and the control group (who received no intervention). In contrast with this study, however, Park and Cho found that systolic blood pressure and triglyceride levels significantly decreased in their foot reflexology group compared to their control group. In addition, life satisfaction was significantly improved in the foot reflexology group. Compared to Park and Cho’s  study (2004), our study was performed using a bigger sample size and with control as a comparison intervention (Park and Cho  , provided foot reflexology only in a small group of 34 hypertensive patients-18 in the foot reflexology group and 16 in the control group who received no intervention). From both studies, we can conclude that foot reflexology has been proved to lower diastolic and systolic blood pressure. However, its effects on quality of life or life satisfaction in patients with hypertension are ambiguous. Our study showed that foot reflexology was more likely to reduce diastolic and systolic blood pressure than control group. Previous studies supporting these results were a study by Hayes & Cox  and another by Jirayingmongkol et al.  . However, these two studies used different measurement and foot massage procedures to test blood pressure. Hayes and Cox  used mean arterial blood pressure as an indicator of measurement of physiological and psychological stress in 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 in participants in the foot massage group compared to those in the control group who received no intervention. Jirayingmongkol et al.  used Thai foot massage which is quite different in style and procedure from the current study to measure vital signs in older subjects. They found that Thai foot massages significantly decreased blood pressure, pulse rate and respiratory rate in these people. Given the differences in measuring, procedures and samples, we can not conclude that foot massage can lower blood pressure in patients with hypertension. Hypothesis two: There is an improvement in mean quality of life between the foot reflexology and control groups at the end of four weeks of treatment p >0.05. Results from this study showed no significant difference in mean quality of life for both groups. These results differed markedly from study results of Park & Cho  and Hodgson  . Park & Cho  showed that foot reflexology significantly improved life satisfaction in 34 patients with hypertension. This study did not support Park and Cho’s  conclusions. Similarly, Hodgson  found that foot reflexology could improve quality of life. However, Hodgson’s study was based on cancer patients and is difficult therefore to compare with the effects of foot reflexology on quality of life in patients with hypertension. In addition, the sample size in her study was small-only twelve subjects including six in the foot reflexology group, and six in the gentle foot massage group. Hodgson used the visual analogue scales for cancer patients to measure quality of life, as contrasted from the current study’s use of the WHOQOLBREF World Health Organization  which is suitable for use with people who have a general chronic disease. There is a little difference in mean quality of life between the foot reflexology and control groups at the end of four weeks of treatment. The evidence relating to foot reflexology, quality of life and patients with hypertension did not indicate that foot reflexology 201 Karima Elshamy & Eman Elsafety can improve quality of life in patients with hypertension. However, the results from open-ended questionnaire showed the benefits from these complementary therapies. These results could well reflect the real benefits of foot reflexology and foot massageto help people feel more comfortable and relaxed, and improve blood circulation in the feet. The results are supported by a study by Long, Huntley & Ernst  who surveyed 223 complementary/ alternative medicine organizations about the benefits of complementary therapies, including reflexology and massage. There was a 34% response rate to their survey, and the results showed that both reflexology and massage were suitable treatments for relieving stress or anxiety, headaches or migraines, and back pain. Limitations of the study: 3- Australian Institute of Health and Welfare: The relationship between overweight, obesity and cardiovascular disease, Australian Institute of Health and Welfare, Canberra, 2004. 4- DEWIT S.C.: Essentials of medical-surgical nursing, 4 th edn, WB Saunders Company, Pennsylvania, 1998. 5- 2- The method of reflexology: This study used Farnsworth’s method of foot reflexology-‘the original western modern foot reflexology method’ Dougans  . Other studies may have used different methods, e.g. the eastern foot reflexology method from China, and achieved different results. 3- Small sample sizes, very specific patient group, limited justification for duration or type of intervention, and/or untested outcome measures. Replication with a larger sample of hypertensive patients is necessary. Conclusion and recommendations: This study supported that foot reflexology can reduce blood pressure levels in patients with hypertension. Future research, which addresses the limitations of this study, could continue the investigations of these claims. Studies are also needed to compare reflexology with other complementary/ alternative therapies (e.g., massage, healing touch, relaxation response), as well as its effect on lipid profiles in hypertensive patients. ! 1- BYERS D.C.: Better health with foot reflexology, Ingham Publishing Inc., Florida, 2001. MONAHAN F.D. and NEIGHORS M.: Medical-surgical 2nd nursing foundations for clinical practice, edn, WB Saunders Company, Pennsylvania, 1998. 6- MACKERETH P.A. and TIRAN D.: Clinical reflexology: A guide for health professionals, Churchill Livingstone, London, 2002. 7- KUHN M.A.: Complementary therapies for health care providers, Lippincott Williams & Wilkins, Philadelphia, 1999. 8- RANKIN-BOX D.: The nurse's handbook of complementary therapies, Harcourt Publishers Ltd, London, 2001. 9- 1- Setting: With limited space, the researchers were unable to have a private room to carry out the treatments. Treatments were provided in rooms at the outpatient department where many patients came to see doctors. Sometimes it was quite noisy. These factors might make it difficult for participants to feel relaxed and therefore achieve the desired effect. References 2- DOUGANS I.: Complete illustrated guide to reflexology, Harper Collins Publishers, London, 2002. 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