Elshamy Karima et al. Effect of Nursing Interventions Using Foot Reflexology on Blood Pressure and Quality of Life of Hypertensive Patients

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 !
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 con-
ducted for patients with hypertension attended the outpatient
clinic of the Specialized Medical Hospital at Mansoura Uni-
versity, 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.
Two tools were used for data collection:
I : Demographic and medical interview schedule.
II: Quality of Life Questionnaire.
Systolic blood pressure decreased significantly in inter-
vention group from 160.2mmHg to 136.5mmHg compared to
(162.5mmHg to 155.2mmHg) in controls. There was a statis-
tically 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.
Key Words: Nursing Intervention – Foot reflexology – Hyper-
tension – Blood pressure – Quality of life.
Introduction
!
HYPERTENSION
is one of the conditions pur-
ported to be improved by complementary therapies
such as foot reflexology
[1,2]
. Hypertension is
Correspondence to:
Dr. Karima Elshamy, Adult Nursing
Department, Faculty of Nursing, Mansoura University,
Email: [email protected]
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] .
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] .
Although not yet widely used, relaxation tech-
niques are potentially valuable nonpharmacological
treatments to lower blood pressure. Such techniques
include progressive muscle relaxation, etc ...
[10] .
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
[11]
; they can also
help improve quality of life
[12] .
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
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] .
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
i
mpact of reflexology on hypotension without any
known reasons, reducing triglyceride and blood
sugar, improving nausea and vomiting in cancer
patients undergoing chemotherapy, reducing de-
pression and improving immune system function,
i
mproving pain and anxiety of the cancer patients
and decrease the fatigue in pregnant women [17] .
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
[11] .
It has been found that health care professionals
have increased their use of complementary therapies
to help relieve uncomfortable symptoms and suf-
fering of patients with chronic diseases [18] . 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 re-
searched 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 [21-
24]
. 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
[24] . Demonstrating concern for patients’ needs
helps to achieve holistic care [25] . Patients with a
chronic disease, who are suffering not only from
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.
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.
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 (inter-
vention) relative to the control group (routine
management) by the end of four weeks of im-
plementation.
Subjects and Methods !
Research design:
A quasi-experimental, pro-
spective 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 pa-
tients 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 hy-
pertension, 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 195
lesions or fractures in foot, sprains or bruises of
the lower extremities, hemorrhage, epilepsy, dia-
betic 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
[28] .
Tools of the study:
Two tools were used in the study:
Tool I:
Demographic and medical interview sched-
ule:
A demographic data questionnaire was written
in Arabic language, This tool was developed by
Soliman H. (2007) in a pervious study which in-
cluded questions on gender, age, marital status,
educational background, economic factors (specif-
ically, whether patients had financial problems),
duration of hypertension, medical history and
treatments, co-morbidities, and top medical treat-
ments. 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
[29] .
Tool II:
Quality of life questionnaire:
The World Health Organization Quality of Life-
BREF, Arabic version (WHOQOL-BREF) ques-
tionnaire was used. The WHOQOL-BREF is a 26-
item, 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 envi-
ronment (eight items). Participants completed this
questionnaire at the start of the study and following
four weeks of intervention
[30] .
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 physiother-
apy for their opinion on the items in the tool and
the criteria. There was complete agreement by
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 hyper-
tensive 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 confiden-
tiality. 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 meth-
odology, 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 Life-
BREF (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 stetho-
scope 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 [31]
. 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 treat-
ment (15m for each foot) twice a week for four
weeks. Participants in the control group received
their routine usual medical treatment which includ-
ed physical examination of feet.
The research assistant conducted the reflexo-
therapy; 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.
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:
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
[32] .
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
lumbar, sacral-coccyx zone. 7. Spinal stretch and
metatarsal knead [32]
.
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 [32]
.
Working the digestive system: 1. Toe walk waist-
line 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
[32] .
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 repro-
ductive 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 [32]
.
Statistical methods:
Random number tables were used to allocate
consecutive eligible patients to either group.

Karima Elshamy & Eman Elsafety 197
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 t -
test 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 reflexol-
ogy 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, smok-
ing, alcohol intake, exercise and recreation / relax-
ation 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, co-
morbidities and medical treatments, marital status,
the length of time experiencing hypertension and
the length of time having treatment for hyperten-
sion.
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 treat-
ment 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 1-
6/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
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 recre-
ation 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 co-
morbidities. 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
Reflexology
Group N=40
(Intervention )
Control
Group N=40
(Routine
management)
N
%
N
%
Gender:
Male 27 67.5 26 65.0
Female 13 32.5
14 35.0
Age/year:
30-40 years 10 25.0 10 25.0
40-50 years
12 30.0 12 30.0
51-60 years 19 47.5 18 45.0
Marital status:
Single 4
10.0 5
12.5
Married
31 77.5 30 75.0
Divorced/separated/
widowed
5
12.5
5
12.5
Level of education:
No education 5
12.5
5
12.5
Primary school 1 2.5 2
5.0
Secondary school 13 32.5 13 32.5
College/university
22 55.0 21
52.5
Economic/financial
difficulties:
Yes 36 90.0 35 87.5
No
4
10.0 5
12.5
Duration of hypertension/
year:
1-5 years 20 50.0
21
52.5
6-10 years 10 25.0 9 22.5
10-15 years 3 7.5 3 7.5
More 15 years 8 20.0 7 17.5
Treatment of hypertension/
year:
1-5 years 19 47.5 18 45.0
6-10 years
11 27.5 12 30.0
10-15 years 5
12.5 4
10.0
More 15 years 5
12.5
6 15.0