MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

reflexology

Please bear with me and have a look at the three short statements quoted below:

1 Reiki

… a Reiki practitioner channels this pure ‘chi’, the ‘ki’ in Reiki, or energy through her hands to the recipient, enhancing and stimulating the individual’s natural ability to restore a sense of wellbeing. It is instrumental in lowering stress levels, and therefore may equip the recipient with increased resources to deal with the physical as well as the emotional, mental and spiritual problems raised by his/her condition. It is completely natural and safe, and can be used alongside conventional medicine as well as other complementary therapies or self-help techniques.

It has been documented that patients receiving chemotherapy have commented on feeling less distress and discomfort when Reiki is part of their care plan. Besides feeling more energy, hope and tranquillity, some patients have felt that the side-effects of chemotherapy were easier to cope with. Reiki has been shown to reduce anxiety and depression, to raise energy levels in tired and apathetic patients. It is of great value in degenerative disease for the very reasons that pain and anxiety can be reduced.

The treatment is gentle, supportive and non-invasive, the patient always remains clothed. Even though the origins of reiki are spiritual in nature, Reiki imposes no set of beliefs. It can be used by people of different cultural backgrounds and faith, or none at all. This makes it particularly suitable in medical settings. Predicting who would or would not like to receive Reiki is impossible.

2 Emmett

EMMETT is a gentle soft tissue release technique developed by Australian remedial therapist Ross Emmett. It involves the therapist using light finger pressure at specific locations on the body to elicit a relaxation response within the area of concern.

Cancer impacts people in different ways throughout the journey of diagnosis, treatment and recovery. Many have found the EMMETT Technique to be very beneficial in a number of ways. Although pressure therapy isn’t new (e.g. acupressure and trigger point therapy are already well known), the amount of pressure required with EMMETT is much lighter and the placement of the pressure is unique to EMMETT Therapy.

Many cancer patients undergo surgery and experience post-surgery tightness and tension around the surgery site in the scar tissue and further afield through the connective tissue or fascia as the body heals. They experience restricted range of movement that may be painful too. Mastectomy patients as an example will usually experience pain or tenderness, swelling around the surgery site, limited arm or shoulder movement, and even numbness in the chest or upper arm. Here’s where EMMETT can assist.  With gentle pressure to specific points, many women have received relief from the pain, reduced swelling and much improved range of movement.  There are multiple EMMETT points that are used to help these women and that give the therapist a range of options depending on the patient’s specific concern.

Many cancer patients also experience fatigue, increased risk of infection, nausea, appetite changes and constipation as common side effects of chemotherapy.  These symptoms can also be greatly supported with a designated sequence where the EMMETT Therapist gently stimulates areas all around the body for an overall effect.  Patients report reduction in swelling, feelings of lightness, increased energy, more robust emotional well-being, less pain and feeling better generally within themselves.

3 Daoyin Tao

The theory behind this massage lies in traditional Chinese medicine, so covers yin and yang, five elements and Chinese face reading from a health perspective.  It enables the emotional elements behind disease to be explored. For example, the Chinese will say that grief is held in the Lung, anger in the liver, and fear in the kidney.

For this half hour massage there is no need for the patient to remove clothes, so it is a lovely way of receiving a massage where body image may be an issue, or where lines and feeds are in place, making removal of clothes difficult. This massage therapy can be given not only in a clinic, but also on the day unit, on hospital wards and even in an intensive care unit.

In working the meridian system the therapist is able to work the whole body, reaching areas other than the contact zone. Patients have commented that this deeply relaxing and soothing massage is; “one of the best massages I have ever had”. It has been proven to be beneficial with problems of; sleep, headaches, anxiety, watery eyes, shoulder and neck tension, sinusitis and panic attacks, jaw tension, fear, emotional trauma/distress.

END OF QUOTES

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Where do you think these statements come from?

They sound as though they come from a profoundly uncritical source, such as a commercial organisation trying to persuade customers to use some dodgy treatments, don’t they?

Wrong!

They come from the NHS! To be precise, they come from the NHS NATURAL HEALTH SCHOOL in Harrowgate, a service that offers a range of free complementary therapy treatments to patients and their relatives who are affected by a cancer diagnosis and are either receiving their cancer treatment at Harrogate or live in the Harrogate and Rural District.

This NHS school offers alternative treatments to cancer patients and claim that they know from experience, that when Complementary Therapies are integrated into patient care we are able to deliver safe, high quality care which fulfils the needs of even the most complex of patients.

In addition, they also run courses for alternative practitioners. Their reflexology course, for instance, covers all of the following:

  • Explore the history and origins of Reflexology
  • Explore the use of various mediums used in treatment including waxes, balms, powders and oils
  • Explore the philosophy of holism and its role within western bio medicine
  • Reading the feet/hands and mapping the reflex points
  • Relevant anatomy, physiology and pathology
  • Managing a wide range of conditions
  • Legal implications
  • Cautions and contraindications
  • Assessment and client care
  • Practical reflexology skills and routines
  • Treatment planning

I imagine that the initiators of the school are full of the very best, altruistic intentions. I therefore have considerable difficulties in criticising them. Yet, I do strongly feel that the NHS should be based on good evidence; and that much of the school’s offerings seems to be the exact opposite. In fact, the NHS-label is being abused for giving undeserved credibility to outright quackery, in my view.

I am sure the people behind this initiative only want to help desperate patients. I also suspect that most patients are very appreciative of their service. But let me put it bluntly: we do not need to make patients believe in mystical life forces, meridians and magical energies; if nothing else, this undermines rational thought (and we could do with a bit more of that at present). There are plenty of evidence-based approaches which, when applied with compassion and empathy, will improve the well-being of these patients without all the nonsense and quackery in which the NHS NATURAL HEALTH SCHOOL seems to specialise.

It is bad enough, I believe, that such nonsense is currently popular and increasingly politically correct, but let’s keep/make the NHS evidence-based, please!

Reflexology is an alternative therapy that is subjectively pleasant and objectively popular; it has been the subject on this blog before (see also here and here). Reflexologists assume that certain zones on the sole of our feet correspond to certain organs, and that their manual treatment can influence the function of these organs. Thus reflexology is advocated for all sorts of conditions, including infant colic.

The aim of this new study was to explore the effect of reflexology on infantile colic.

A total of 64 babies with colic were included in this study. Following a paediatrician’s diagnosis, two groups (study and control) were created. Socio-demographic data (including mother’s age, educational status, and smoking habits of parents) and medical history of the baby (including gender, birth weight, mode of delivery, time of the onset breastfeeding after birth, and nutrition style) were collected. The Infant Colic Scale (ICS) was used to estimate the colic severity in the infants. Reflexology was applied to the study group by the researcher and their mother 2 days a week for 3 weeks. The babies in the control group did not receive reflexology. Assessments were performed before and after the intervention in both groups.

The results show that the two groups were similar regarding socio-demographic background and medical history. While there was no difference between the groups in ICS scores before application of reflexology, the mean ICS score of the study group was significantly lower than that of control group at the end of the intervention.

The authors concluded that reflexology application for babies suffering from infantile colic may be a promising method to alleviate colic severity.

The authors seem to attribute the outcome to specific effects of reflexology.

However, they are mistaken!

Why?

Because their study does not control for the non-specific effects of the intervention.

Reflexology has not been shown to work for anything (“the best clinical evidence does not demonstrate convincingly reflexology to be an effective treatment for any medical condition“), and there is plenty of evidence to show that holding the baby, massaging it, cuddling it, rocking it or doing just about anything with it will have an effect, e. g.:

This trial of massage treatment for infantile colic showed statistically significant or clinically relevant effect in comparison with the rocking group.

The majority of the included trials appeared to indicate that the parents of infants receiving manipulative therapies reported fewer hours crying per day than parents whose infants did not…

…kangaroo care for infants with colic is a promising intervention…

I think, in a way, this is rather good news; we do not need to believe in the hocus-pocus of reflexology in order to help our crying infants.

In part one, we have dealt with three common tricks used by quacks to convince the public to consult them and to keep coming back for more. It has been pointed out to me that some of these tricks are used not just by alternative practitioners but also by real physicians. This is, of course, absolutely true. A quack can be defined as “a person who dishonestly claims to have special knowledge and skill in some field, typically medicine.” Therefore real doctors can be real quacks, of course. I happen to have an interest mainly in alternative medicine; that’s why I write about these type of quacks (if it helps keeping you blood pressure within the limits of normal, I can tell you that I occasionally also published about quackery in mainstream medicine, for instance here).

Anyway, now it is time to continue this series of posts by discussing three further common deceptions used by quacks.

A CURE TAKES A LONG TIME

Imagine a scenario where, even after, several therapy sessions, a patient’s condition has not improved. Let’s assume the problem is back pain, and that it has not improved a  bit despite the treatments and the money spent on it. Surely, many patients in such a situation are sooner or later going to give up. They will have had enough! And this is, of course, a serious threat to the practitioner’s cash flow.

Luckily, there is a popular ploy to minimize the risk: the practitioner merely has to explain that the patient’s condition has been going on for a very long time (if, in the above scenario, this were not the case, the practitioner would explain that the pain might be relatively recent but the underlying condition is chronic). This means that a cure will also have to take a very long time – after all, Rome was not built in one day!

This plea to carry on with the ineffective treatments despite any improvement of symptoms is usually not justifiable on medical grounds. It is, however, entirely justifiable on the basis of financial considerations of the practitioners. They rely on their patients’ regular payments and will therefore think of all sorts of means to achieve this aim.

Take my advice and see a clinician who can help you within a reasonable and predictable amount of time.

IT’S DUE TO THE POISONS YOUR DOCTOR GAVE YOU

In the pursuit of a healthy cash-flow, almost all means seem to be allowed – even the fabrication of the bogus notion that the reasons for the patient’s problem were the poisonous drugs prescribed by her doctor who, of course, is in cahoots with BIG PHARMA. Alternative medicine thrives on conspiracy theories, and the one of the evil ‘medical mafia’ is one of the all-time favourites. It enables scrupulous practitioners to instil a good dose of fear into the minds of their patients, a fear that minimises the risk of them returning to real medicine.

My advice is that alternative practitioners who habitually use this or any other conspiracy theory should be avoided at all costs.

THINK HOLISTICALLY

The notion that alternative medicine takes care of the whole person is a most attractive and powerful ploy. Never mind that nothing could be further from being holistic than, for instance, diagnosing conditions by looking at a patient’s iris (iridology), or focussing on her spine (chiropractic, osteopathy), or massaging the soles of her feet (reflexology). And never mind that any type of good conventional medicine is by definition holistic. What counts is the label, and ‘holistic’ is a most desirable one, indeed. Nothing sells quackery better than holism.

Most alternative practitioners call themselves holistic and they rub the holism into the minds of their patients whenever and however they can. This insistence on holism has the added advantage that they have seemingly plausible excuses for their therapeutic failures.

Imagine a patient consulting a practitioner with depression and, even after prolonged treatment, her condition is unchanged. Even in such a situation, the holistic practitioner does not need to despair: he will point out that he never treats diagnostic labels but always the whole person. Therefore, the patient’s depression might not have changed, but surely other issues have improved… and, if the patient introspects a little, she might find that her appetite has improved, that her indigestion is better, or that her tennis elbow is less painful (some things always change given enough time). The holism of quacks may be a false pretence, but its benefits for the practitioner are obvious.

My advice: take holism from quacks with a pinch of salt.

Alternative medicine has no shortage of research that suggests it to be effective. Almost invariably, however, one finds – when looking a bit more carefully at such investigations – that the positive conclusions are not warranted by the data. Here is an excellent, recent example:

This new study, authored by two Turkish nurses, was an RCT where the patients were randomly assigned to either an aromatherapy massage (n = 17), reflexology (n = 17) or the control group (n = 17). Aromatherapy massage was applied to both knees of subjects in group 1 for 30 minutes. Reflexology was administered to both feet of subjects in group 2 for 40 minutes during weekly home visits. The subjects of group 3, the control group, received no intervention.

Fifty-one subjects with rheumatoid arthritis were recruited from a university hospital rheumatology clinic in Turkey between July 2014 and January 2015 for this trial. Data were collected by personal information form, DAS28 index, Visual Analog Scale and Fatigue Severity Scale. Pain and fatigue scores were measured at baseline and within an hour after each intervention for 6 weeks.

Pain and fatigue scores significantly decreased in the aromatherapy massage and reflexology groups compared with the control group (p < .05). The reflexology intervention started to decrease pain and fatigue scores earlier than aromatherapy massage (week 1 vs week 2 for pain, week 1 vs week 4 for fatigue) (p < .05).

The authors concluded that aromatherapy massage and reflexology are simple and effective non-pharmacologic nursing interventions that can be used to help manage pain and fatigue in patients with rheumatoid arthritis.

I am sure that most readers have spotted the snag: the two interventions generated better outcomes than no therapy. It is quite simply wrong to assume that this outcome is specifically related to the two treatments. Both of these treatments are fairly agreeable and generate expectations, involve touch, attention and care. In my view, it is these latter factors which together have caused the better outcomes. And this is, of course, entirely unrelated to any specific effects of the two therapies.

This might well be trivial, but if such sloppy conclusions pollute the literature to the extend that they currently do in the realm of alternative medicine, it becomes important.

Reflexology is the treatment of reflex zones, usually on the sole of the feet, with manual massage and pressure. Reflexologists assume that certain zones correspond to certain organs, and that their treatment can influence the function of these organs. Thus reflexology is advocated for all sorts of conditions. Proponents are keen to point out that their approach has many advantages: it is pleasant (the patient feels well with the treatment and the therapist feels even better with the money), safe and cheap, particularly if the patient does the treatment herself.

Self-administered foot reflexology could be practical because it is easy to learn and not difficult to apply. But is it also effective? A recent systematic review evaluated the effectiveness of self-foot reflexology for symptom management.

Participants were healthy persons not diagnosed with a specific disease. The intervention was foot reflexology administered by participants, not by practitioners or healthcare providers. Studies with either between groups or within group comparison were included. The electronic literature searches utilized core databases (MEDLINE, EMBASE, Cochrane, and CINAHL Chinese (CNKI), Japanese (J-STAGE), and Korean databases (KoreaMed, KMbase, KISS, NDSL, KISTI, and OASIS)).

Three non-randomized trials and three before-and-after studies met the inclusion criteria. No RCTs were located. The results of these studies showed that self-administered foot reflexology resulted in significant improvement in subjective outcomes such as perceived stress, fatigue, and depression. However, there was no significant improvement in objective outcomes such as cortisol levels, blood pressure, and pulse rate. We did not find any randomized controlled trial.

The authors concluded that this study presents the effectiveness of self-administered foot reflexology for healthy persons’ psychological and physiological symptoms. While objective outcomes showed limited results, significant improvements were found in subjective outcomes. However, owing to the small number of studies and methodological flaws, there was insufficient evidence supporting the use of self-performed foot reflexology. Well-designed randomized controlled trials are needed to assess the effect of self-administered foot reflexology in healthy people.

I find this review quite interesting, but I would draw very different conclusions from its findings.

The studies that are available turned out to be of very poor methodological quality: they lack randomisation or rely on before/after comparisons. This means they are wide open to bias and false-positive results, particularly in regards to subjective outcome measures. Predictably, the findings of this review confirm that no effects are seen on objective endpoints. This is in perfect agreement with the hypothesis that reflexology is a pure placebo. Considering the biological implausibility of the underlying assumptions of reflexology, this makes sense.

My conclusions of this review would therefore be as follows: THE RESULTS ARE IN KEEPING WITH REFLEXOLOGY BEING A PURE PLACEBO.

Reflexology? Isn’t that an alternative therapy? And as such, a physiotherapist would not normally use it, most of us might think.

Well, think again! Here is what the UK Chartered Society of Physiotherapists writes about reflexology:

Developed centuries ago in countries such as China, Egypt and India, reflexology is often referred to as a ‘gentle’ and ‘holistic’ therapy that benefits both mind and body. It centres on the feet because these are said by practitioners to be a mirror, or topographical map, for the rest of the body. Manipulation of certain pressure, or reflex, points is claimed to have an effect on corresponding zones in the body. The impact, say reflexologists, extends throughout – to bones, muscles, organs, glands, circulatory and neural pathways. The head and hands can also be massaged in some cases. The treatment is perhaps best known for use in connection with relaxation and relief from stress, anxiety, pain, sleep disorders, headaches, migraine, menstrual and digestive problems. But advocates say it can be used to great effect far more widely, often in conjunction with other treatments.

Reflexology, or Reflex Therapy (RT) as some physiotherapists prefer to call it, clearly is approved by the UK Chartered Society of Physiotherapists. And what evidence do they have for it?

One hundred members of the Association of Chartered Physiotherapists in Reflex Therapy (ACPIRT) participated in an audit to establish a baseline of practice. Findings indicate that experienced therapists use RT in conjunction with their professional skills to induce relaxation (95%) and reduce pain (86%) for patients with conditions including whiplash injury and chronic pain. According to 68% of respondents, RT is “very good,” “good” or “as good as” orthodox physiotherapy practices. Requiring minimal equipment, RT may be as cost effective as orthodox physiotherapy with regards to duration and frequency of treatment.

But that’s not evidence!!! I hear you grumble. No, it isn’t, I agree.

Is there good evidence to show that RT is effective?

I am afraid not!

My own systematic review concluded that the best evidence available to date does not demonstrate convincingly that reflexology is an effective treatment for any medical condition.

Does that mean that the Chartered Society of Physiotherapists promotes quackery?

I let my readers answer that question.

Many proponents of alternative medicine seem somewhat suspicious of research; they have obviously understood that it might not produce the positive result they had hoped for; after all, good research tests hypotheses and does not necessarily confirm beliefs. At the same time, they are often tempted to conduct research: this is perceived as being good for the image and, provided the findings are positive, also good for business.

Therefore they seem to be tirelessly looking for a study design that cannot ‘fail’, i.e. one that avoids the risk of negative results but looks respectable enough to be accepted by ‘the establishment’. For these enthusiasts, I have good news: here is the study design that cannot fail.

It is perhaps best outlined as a concrete example; for reasons that will become clear very shortly, I have chosen reflexology as a treatment of diabetic neuropathy, but you can, of course, replace both the treatment and the condition as it suits your needs. Here is the outline:

  • recruit a group of patients suffering from diabetic neuropathy – say 58, that will do nicely,
  • randomly allocate them to two groups,
  • the experimental group receives regular treatments by a motivated reflexologist,
  • the controls get no such therapy,
  • both groups also receive conventional treatments for their neuropathy,
  • the follow-up is 6 months,
  • the following outcome measures are used: pain reduction, glycemic control, nerve conductivity, and thermal and vibration sensitivities,
  • the results show that the reflexology group experience more improvements in all outcome measures than those of control subjects,
  • your conclusion: This study exhibited the efficient utility of reflexology therapy integrated with conventional medicines in managing diabetic neuropathy.

Mission accomplished!

This method is fool-proof, trust me, I have seen it often enough being tested, and never has it generated disappointment. It cannot fail because it follows the notorious A+B versus B design (I know, I have mentioned this several times before on this blog, but it is really important, I think): both patient groups receive the essential mainstream treatment, and the experimental group receives a useless but pleasant alternative treatment in addition. The alternative treatment involves touch, time, compassion, empathy, expectations, etc. All of these elements will inevitably have positive effects, and they can even be used to increase the patients’ compliance with the conventional treatments that is being applied in parallel. Thus all outcome measures will be better in the experimental compared to the control group.

The overall effect is pure magic: even an utterly ineffective treatment will appear as being effective – the perfect method for producing false-positive results.

And now we hopefully all understand why this study design is so very popular in alternative medicine. It looks solid – after all, it’s an RCT!!! – and it thus convinces even mildly critical experts of the notion that the useless treatment is something worth while. Consequently the useless treatment will become accepted as ‘evidence-based’, will be used more widely and perhaps even reimbursed from the public purse. Business will be thriving!

And why did I employ reflexology for diabetic neuropathy? Is that example not a far-fetched? Not a bit! I used it because it describes precisely a study that has just been published. Of course, I could also have taken the chiropractic trial from my last post, or dozens of other studies following the A+B versus B design – it is so brilliantly suited for misleading us all.

Reflexology is one of the most popular of all alternative therapies. Anyone who has ever had a session knows why: it is a strangely pleasant and oddly agreeable experience. Reflexologists massage your feet which can be mildly painful but usually is quite relaxing. They look for and subsequently focus on areas of tenderness believing they correspond to specific organs or whole organ systems. Even though few reflexologists would admit to it, they tend to make vague and unreliable diagnoses: if they feel something unusual at a certain point of the sole of your foot, they assume that a certain inner organ is in trouble. Reflexologists even have maps where the sole of a foot is depicted showing which area corresponds to which organ.

The treatment might be enjoyable but the assumptions that underpin it are nonsensical for at least two reasons: firstly, there are no nerve or other connections between a specific area on the sole of a foot and a certain organ. Secondly, the maps which reflexologists employ differ and fail to agree which area corresponds to which organ. Thus there are inconsistencies within the realm of reflexology and there are inconsistencies in relation to the known facts regarding physiology, anatomy etc.

Proponents of reflexology are quite undisturbed by these problems and seem to believe that not their assumptions but science must be wrong. After all, reflexology does work! That is to say that patients perceive benefit from it, pay out of their own pocket for the experience and tend to come back for more.

Several years ago, we asked 8 UK professional organisations of reflexology which conditions they thought could be treated effectively with reflexology. We gave them a list of 25 conditions to chose from, many of which were serious, e.g. cancer and AIDS. Collectively, the organisations felt that 22 of these illnesses would respond to reflexology.

But this is opinion, not evidence! What do the trial data tell us? Is reflexology more than a placebo?

As with many other areas of alternative medicine, controlled clinical trials are scarce; but this is not to say that none at all are available. Our own trial of reflexology for menopausal symptoms failed to show that this therapy has any effects beyond placebo. More recently, we published a systematic review to evaluate all of the 23 studies that had been published at that stage. They related to a wide range of medical conditions and their methodological quality was often poor. Nine high quality randomised clinical trials (RCTs) generated negative findings. Eight RCTs suggested that reflexology is effective for the following conditions: diabetes, premenstrual syndrome, cancer patients, multiple sclerosis, symptomatic idiopathic detrusor over-activity and dementia. These studies, however, were wide open to bias. Therefore, our conclusions had to be cautious: the best clinical evidence does not demonstrate convincingly reflexology to be an effective treatment for any medical condition.

For you and me, this simply means that there is currently no good evidence to suggest that reflexology works. But the story does not end here. There will be more studies and enthusiasts are most likely to concede that our conclusions were incorrect. In fact, a further trial has just become available.

This new single-blind, randomized and placebo controlled study included 20 moderately to severely affected multiple sclerosis patients. Each participant received for 8 weeks, 1 hour per week of either reflexology or sham reflexology. The primary outcome measure was the Multiple Sclerosis Impact Scale at baseline, 8 weeks and 16 weeks. The results revealed improvements in both groups but no statistically significant differences between the two groups at either 8 or 16 weeks. The conclusions of the investigators were clear: The results do not support the use of reflexology for symptom relief in a more disabled multiple sclerosis population and are strongly suggestive of a placebo response.

There is, of course, nothing wrong with a relaxing foot-massage; it is agreeable, no doubt, and if someone wants to pay for the luxury, why not? By contrast, there is a lot wrong with reflexology, I think. A foot-massage is not administered under the pretence of generating any specific therapeutic effects. Reflexologists, however, claim they can exert highly specific effects on inner organs, influence the natural history of a wide range of diseases, and provide reliable diagnoses. They thus mislead their clients. This is not just wrong, it also has the potential to do serious harm. I believe it is time to end this nonsense.

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