25. Reflexology

Reflexology did not gain popularity until the 20th century although its history may date back much further.
This chapter will include the following sections:

Reflexology used to be known as zone therapy. Therapeutic massage of the feet may go back to Ancient Egypt some 4,000 years ago, or even further back in China. The concept of “zone therapy” appears to date back to the 16th century but did not gain much popularity until around the turn of the 20th century. It was called zone therapy until physiotherapists objected to the term “therapy” and the term “reflexology” was coined in 1961.

Nearly all treatment is obtained outside the NHS. It is rarely or never performed by medical practitioners.

Mechanism of Action

There is much less research on the proposed mechanism of action of reflexology than on acupuncture or manipulation. It is said that the areas activated by massage of the feet may have something in common with the lines of chi or qi in acupuncture. However, these lines have never been demonstrated. The technique may also involve massage of the hands.

A map on the feet purporting to show how the organs of the body are related to pressure points on the feet

According to some promotional material, “Reflexologists believe that the feet mirror the body. All organs, systems and glands of the body can be mapped onto areas of the feet called reflex points. A reflexologist knows how to stimulate the reflex points in order to bring about a response in the corresponding part of the body.”1What is reflexology? I have changed the reference to the Association of Reflexologists as the original site is no longer online.

It is quite clear from this that there is no credible basis for reflexology. However, being without a rationale does not mean that it is ineffective. We must consider the evidence.

Evidence of Effectiveness

The York Centre for Reviews and Dissemination has produced one of the few, if not the only review of scientific publications about reflexology.2Reflexology: an update of a systematic review of randomised clinical trials The main reviewer was Professor Ernst from Exeter. It dates from August 2001 but was updated in 2011. There was still the problem of poor methodology. His opinion that its efficacy is still unproven remained unchanged.

Only seven trials were included, five of randomised design with a total of 214 participants overall. All of the studies had methodological flaws, including small sample size. Their conclusion was, “There are few controlled trials on reflexology. Of those that have been published, all are methodologically flawed and their results are non-uniform. The effectiveness of reflexology is not supported by controlled clinical trials.” They are not saying that it does not work but that the scientific basis of trials is so poor that it is impossible to draw any valid conclusion either way.

When every type of treatment is a success, it is time to be sceptical

The Prince of Wales’ Foundation for Integrated Health produced a series of conferences in 2003 and 2004 called “Searching for Evidence. Complementary therapies research”. Reflexology was one of the topics included. Areas covered, with reference to reflexology included premenstrual syndrome, menopausal symptoms, pain, nausea and vomiting in early pregnancy, mental health in primary care and chronic fatigue syndrome. A striking observation about this selection of conditions is that every one may be expected to have a very high placebo response rate. Every type of treatment was lauded as a great success at the conference. This in itself should raise concern amongst the objective. Many trials were not placebo controlled. For many individual trials there were results that were at variance with conclusions of Cochrane reviews. This does not apply for reflexology as there has never been a Cochrane review of reflexology.

The Foundation for Integrated Health was an organisation founded by the Prince of Wales in his quest to have CAM integrated into scientific medicine. He is an altruistic person with admirable ideals but his lack of education in science makes him very gullible and susceptible to groundless claims. The foundation was wound up in 2010 after problems of fraud at the top of its administration.3Prince Charles charity to close amid fraud inquiry This was financial rather than scientific fraud and the prince was not implicated personally.

Getting an adequate placebo is a problem

Controls for trials of reflexology have been a problem, as with manipulation and acupuncture although in the latter some very ingenious techniques have been developed. Where controls have been used, the usual technique is to insist that subjects have not previously experienced reflexology and the intervention involves pressure and massage of the feet but not in the correct manner as taught to exponents. However, there is a problem if the correct application of the procedure is not as important as has been taught. The dummy intervention may have a degree of effectiveness and this will improve the outcome in the placebo group, making any improvement in the intervention group less impressive. There is a good analogy with acupuncture where there is evidence that superficial needling or slight misplacing of the needles may have more than placebo effect.

There was a paper in the British Journal of General Practice in 2002 that aimed to assess the value of reflexology for irritable bowel syndrome.4A single-blind trial of reflexology for irritable bowel syndrome There was a tight definition of the condition being treated, using the Rome criteria. The condition was stable at the time. A sham treatment was used as control. Valid end points were used for assessment and the patients, but not the practitioner, were blind as to intervention. There was no significant difference between treatment and control groups. The methodology of this study was very much better than so many others had been. It was a pity that it was stopped just short of the number needed to have an 80% chance of demonstrating a difference at the 0.05 level of probability, if it exists. This is generally accepted as the level to draw a conclusion about efficacy. In other words, it was slightly underpowered.

Another paper came from Indianapolis and reviewed the literature with regard to CAM treatment of menopausal symptoms. No benefit was found for reflexology.5Other complementary and alternative medicine modalities: acupuncture, magnets, reflexology, and homeopathy

A website by two American reflexologists calls itself “reflexology research”. It suggests that there is evidence that reflexology may improve relaxation and reduce stress. No references are given and so it is impossible to assess the validity of the quoted research.6Reflexology Research The website may be interesting to give an idea of some of the theory behind the technique. It is possible that if it has any benefit over and above the placebo effect, it is related to relaxation. This can be valuable in conditions in which there is psychological tension or a significant psychosomatic element. This impression is reinforced by perusal of papers on reflexology that have reached PubMed.

Cost

According to the York Review, in the UK, the cost of one reflexology session is usually between £14 and £35. The usual duration of treatment is 6 to 8 sessions that could cost as much as £240. If patients consult with chronic conditions that require repeated attention throughout the year, an expenditure of £1,000 per patient per year would not be exceptional. These figures are rather old and costs may be rather higher now.

Professional Regulation

Professional regulation for reflexology is on a voluntary basis with no plans for compulsory regulation.

Conclusion

There is no plausible theory behind reflexology. Even if it is related to the lines of chi or qi in acupuncture, these have never been demonstrated in an objective way. The idea of crystals in the tissues is just fanciful.

It is impossible to give a firm verdict on efficacy because the quantity of research has been so limited and the quality of research has been so poor. Poor methodology involves not just lack of adequate control but failure to determine a valid objective and form of measurement from the outset, inadequate randomization and under-powered studies with small numbers.

It is unlikely to do any significant harm unless serious disease is left untreated. That is the only apparent reason for professional registration.

On the basis of the evidence available, reflexology cannot be recommended as a form of treatment for any condition.

Further Resources

References

  1. Association of Relexologists. What is reflexology?
    https://www.aor.org.uk/home/what-is-reflexology
  2. Ernst E, Posadzki P, Lee MS. Reflexology: an update of a systematic review of randomised clinical trials. Maturitas. 2011 Feb;68(2):116-20. Epub 2010 Dec 15.
    http://www.ncbi.nlm.nih.gov/pubmed/21111551
  3. Prince Charles charity to close amid fraud inquiry. BBC News 30 April 2010.
    http://news.bbc.co.uk/1/hi/uk/8654679.stm
  4. Tovey P. A single-blind trial of reflexology for irritable bowel syndrome. Br J Gen Pract. 2002 Jan;52(474):19-23.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314196/pdf/11791811.pdf
  5. Carpenter JS, Neal JG; Other complementary and alternative medicine modalities: acupuncture, magnets, reflexology, and homeopathy.; Am J Med. 2005 Dec 19;118(12 Suppl 2):109-17.
    http://www.ncbi.nlm.nih.gov/pubmed/16414335
  6. Barbara and Kevin Kunz. Reflexology research.
    http://www.reflexology-research.com

Site Index

This website is now completed, although I shall continue to do updates. The following list shows the sections or chapters. Just click on the topic in blue to go to that part of the site.

1 Introduction
2 A Very Brief History of Science And Medicine
  Fundamentals of Medical Science
3 Finding Good Medical Advice and Evidence Based Medicine
4 Randomised Controlled Trials
5 Cohort or Longitudinal and Epidemiological Studies
6 Qualitative Research
7 Basic Maths in Medical Research and Decision Making
8 How Good is the Evidence?
9 Ethics in Practice and Research
  Public Health Issues
10 Screening Programmes
11 Fake News and Vaccine Scares
12 Electronic Cigarettes (E-Cigarettes)
13 Motor Vehicle Emissions, Air Pollution and Health
  COVID-19
14 COVID-19. What You Need to Know
15 Who is at Risk from COVID-19
16 What we Must Learn from the COVID-19 Pandemic
  Nutrition
17 Basics of Nutrition
18 Exercise, Obesity and Diets for Weight Loss
19 Diets and Nutrition for Health and Fitness
20 Supplements
  Complementary and Alternative Medicine
21 Introduction to Alternative Healthcare
22 Homeopathy
23 Acupuncture
24 Manipulation of the Spine
25 Reflexology
26 Herbal Remedies
27 Other Natural Products
28 Chelation Therapy
29 Hypnosis
30 Other Modalities of Complementary and Alternative Medicine
  Some Controversial Diseases
31 Fibromyalgia
32 Chronic Fatigue Syndrome (CFS) or Myalgic Encephalitis (ME)
33 Systemic Candidiasis and Leaky Gut Syndrome
34 Mobile Phones, Masts, Wi-Fi and Electro-sensitivity
  The Environment
35 Global Warming and Climate Change
36 Alternative Energy
  Some Final Thoughts
37 Still Searching for the Age of Reason