Complementary Therapies in Clinical Practice 16 (2010) 167–172

Contents lists available at ScienceDirect

Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctnm

Effects of reflexology on fibromyalgia symptoms: A multiple case study

Thora Jenny Gunnarsdottir a, *, c, Cynthia Peden-McAlpine b, d
a
Faculty of Nursing, University of Iceland, Reykjavik, Iceland
b
University of Minnesota, School of Nursing, MN, USA

a b s t r a c t

Keywords: Purpose: To explore the effects of reflexology on pain and other symptoms in women with fibromyalgia
Reflexology syndrome [FM].
Fibromyalgia syndrome Methods: Multiple case study method as developed by Stake was used to investigate the effects of
Multiple case study
reflexology on six cases of women with FM which were given ten sessions of weekly reflexology. Data
Nursing
were collected with observation, interviews and diary and then analyzed within cases and across cases.
Symptom
Results: Reflexology affected the symptom of pain in multiple areas such as head, neck and arms. Pain
started to isolate and decrease.
Conclusion: Reflexology may be helpful to decrease fibromyalgia symptoms. Qualitative research methods
and individually tailored interventions are important when researching complementary and alternative
therapies.
Ó 2010 Elsevier Ltd. All rights reserved.

1. Introduction nonpharmacological agents8 have been found to be universally

Fibromyalgia syndrome (FM) is a rheumatologic syndrome,
manifested as a chronic disease with diffuse musculoskeletal
aching and soreness, accompanied by poor sleep, fatigue, and
morning stiffness.1 The etiology in FM is not fully known. Muscle
abnormalities, sleep disturbances, and a biochemical unbalanced
metabolism have all been considered as playing a part in FM.2
Fibromyalgia tends to be more common among women than
men, with female prevalence ranging from 73% to 88%.2 The impact
of this disease is severe for patients, both physically and econom-
ically and studies have found that 44% of patients with FM may be
unable to perform household tasks without assistance.3 FM
patients often feel disabled by fatigue and may not be able to hold
a full-time job or perform everyday activities.3
Conventional medicine falls short in providing expected sus-
tained relief from pain in patients with FM.4 No treatment inter-
ventions, whether pharmacological,5 lifestyle manipulations,6,7 or
* Corresponding author. Tel.: þ354 5254982; fax: þ354 5254963.
E-mail addresses: thoraj@hi.is (T.J. Gunnarsdottir), peden001@umn.edu (C.
Peden-McAlpine).
c
Thora J. Gunnarsdottir is assistant professor at the Faculty of Nursing at the
University of Iceland. Her program of research is in complementary and alternative
therapies in nursing practice.
d
Cynthia Peden-McAlpine is associate professor at the University of Minnesota,
School of Nursing. Her program of research includes expertise in qualitative meth-
odology, clinical judgment and reflective practice strategies and the inclusion of
families in the end of live care.
successful in improving the symptoms of FM. Patients with FM have
been reported to have explored complementary and alternative
therapies (CAT).9 An assessment of the use and satisfaction with
alternative medicine practices used by FM patients and a compar-
ison of FM to other rheumatology patients were done in a study in
Canada.10 The findings indicated that 73 (91%) of FM patients
identified alternative medicine use, compared to 140 (63%) of
control patients. Few rigorous studies have demonstrated the
effects of reflexology as an effective treatment for chronic
symptoms.
2. Background
Reflexology is a specific pressure technique that works on
precise reflex points of the feet, based on the premise that reflex
areas on the feet correspond to all body parts. Because the feet
represent a microcosm of the body, all organs, glands, and other
body parts are laid out in a similar arrangement on the feet.11 The
literature implies that reflexology is useful for achieving and
maintaining health, enhancing wellbeing, and helpful for relieving
the symptoms of illness and disease.12,13
Studies of reflexology have been reported to help to alleviate the
effects of stress by inducing deep relaxation so one’s body can
regain homeostasis,11,14 decrease anxiety in patients with breast
and lung cancer,15 increase comfort and quality of life in patients
with cancer16 and Multiple Sclerosis.17 It has also been shown to
help migraine patients relief headache and reduce pain medication
intake,18 and relieve symptoms of multiple sclerosis.17,19,20 The

1744-3881/$ – see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ctcp.2010.01.006
168 T.J. Gunnarsdottir, C. Peden-McAlpine / Complementary Therapies in Clinical Practice 16 (2010) 167–172
effect of reflexology on symptoms of fibromyalgia has not been
reported in previous studies. A recent systematic review of the
efficacy of reflexology states that there is no evidence for any
specific effect of reflexology in any conditions except of urinary
symptoms associated with multiple sclerosis.21 The authors did
therefore not recommend routine provision of reflexology.
However in a study of the effects of reflexology on patients
undergoing coronary artery bypass graft surgery it is suggested that
reflexology should be tailored to individual needs and research
methods used that allow for capturing its holistic nature.22
3. Methods
3.1. Study design
Given the questionable evidence base of the state of reflexology
research and the need to allow for individually based treatments
led the researchers to do a systematic and inductive study of
reflexology, using a qualitative design; the multiple case study
method as described by Robert Stake.23 In this study, each case
consists of one participant suffering from Fibromyalgia Syndrome
(FM) who undergoes 10 reflexology sessions. Each case was looked
at individually and then the cases were collapsed together in order
to make assertions about reflexology for FM patients. Each case to
be studied has its own problems, and stories to tell but the main
research interest is in the evaluation of multiple cases.
The main research question focused on was: Do the participants
experience changes of pain or other symptoms during multiple
reflexology treatments in the study period?
3.1.1. Procedures and setting
An MD who specializes in treating patients with FM recruited
eligible participants, men or women, who were diagnosed with FM
according to the American College of Rheumatology criteria
(Table 1). Six women with FM took part in the study. The youngest
one 27 years old, and the oldest 55 yr, with a mean age of 39 years.
Four of them were married with children. They had all been
recently diagnosed with FM, although some of them had been
battling with symptoms for years. An average of four to ten cases is
thought to be most appropriate for a multiple case study.23
The necessary steps to obtain permission and authorization
through the Institutional Review Board (IRB) at the University of
Minnesota, from Protection of Personal Data in Iceland, and from
The National Bioethics Committee in Iceland were obtained.
Written consent was also obtained from all participants involved in
the study.
The reflexology sessions took part in a reflexology clinic. One
reflexologist administered all reflexology treatments in the study in
order to reduce any possible inter-rater reliability issues. All of the
areas in the feet were assessed and worked on during the first
session. In the second session, a comprehensive assessment was
done again on both feet, and each participant was asked specifically
about his/her state in connection to the findings from the former
session. These findings guided the second session; whatever was
Table 1
Guidelines for inclusion/exclusion.
18 years or older
Native speaking
Diagnosed with FM
Having both feet and all toes intact and free from wounds
No use of other complementary or alternative therapies during study
Has no other significant health problem unrelated to FM
No use of sleep medications
No use of sedative or sleeping medications
Referred by MD specialist in FM
found to be imbalanced was worked on, depending on each
participant. The 10 sessions proceeded in the following manner:
a period of 45 min was estimated to be adequate time to perform
reflexology on both feet; however, extra time was allowed for
specific work on areas needing further care. At the end of each
session, the participant relaxed for at least 10–15 min.
4. Data collection
Data were collected trough three major sources; interviews,
observation and diary. The purpose of the interviews was to serve
as a resource for developing a richer and deeper understanding of
how the women experienced the effects of reflexology on their
symptom experience, specifically on pain. All interviews were
conducted privately, tape-recorded and transcribed. The researcher
was present in the field during all of the sessions, recording and
making field notes of what was taking place. The participants filled
out a symptom diary for 13 weeks. The diary started one week
before the first reflexology session and the diary writing finished
two weeks after the last reflexology session. During each day of the
study the participants were to write down any specific notions of
symptoms such as their reflections on the quality of their sleep,
medication intake and any sensations of pain or any other aggra-
vating symptoms or benefits. If they were experiencing pain, they
were asked to mark all of the different sites of their pain on
a diagram of a body and to evaluate the strength of the pain at each
site using a Numerical Rating Scale (NRS). The zero point indicates
‘‘no pain at all’’ while 10 indicates ‘‘the worst pain imaginable.’’ The
participants were asked to mark a score on the line corresponding
to the amount of pain sensation they experienced.
4.1. Data analysis
Data were analyzed both within case and cross cases.23 In the
within case analysis all of the data for each case were reviewed, and
a general description of the experience of reflexology on pain and
symptoms was recorded. Each participant’s pain was mapped out
to give a graphic format of how it was experienced during the study
according to the diary. The main activity of a cross-case analysis
consisted of reading the case reports as a whole, all of the original
data, with special attention to the commonalities, uniqueness,
confusions, contraindications and missing information between
the cases regarding any salient issues.
5. Results
5.1. Within case analysis
A very short description is given for each participant that
focuses on the experience of pain as it was reflected during the
study and a graph of pain experience of each participant is
provided.
The first participant Anna has been battling symptoms of pain
with fatigue for over twenty years. She has difficulty describing her
pain. Some days it is only light obtuse pain, but other days, it feels
like a throbbing pain. Anna described several changes in pain that
had occurred during the sessions. She actually felt worse during the
first weeks of the study especially having bad headaches and neck
pain during the first two weeks and she had to try hard to keep
herself from taking medications which she didn’t want to do. In
session five when the therapist was working to relief her headache,
Anna noticed how the fog had disappeared from her head, making
herself feel mentally ‘‘lighter.’’ She took deep breaths and then said,
‘‘The veil has gone from my head; it is just gone.’’ She could feel
how it suddenly had gotten lighter and the heaviness over her head
 T.J. Gunnarsdottir, C. Peden-McAlpine / Complementary Therapies in Clinical Practice 16 (2010) 167–172 169

had disappeared. This heavy sensation did not return during the Pain level
study period. The diagram of pain over the study period shows this 10

well for Anna (Fig. 1). At the end of the study she reported less pain 9

in her head, arms, hips and elbows. Additionally, the pain in her hip 8

joints and in her fingers became much better and her perspiration 7

had become much less than before. What did not change was the 6

pain around the coccyx. 5

Betsy described her pain as a throbbing-like sensation of being 4

stabbed in several places by a knife, but also experienced stiffness 3

and numbness, especially in the mornings. As evident in the 2

diagram made from Betsy’s experience of pain during the study 1

(Fig. 2) she first gets worse but then much better around week
seven and eight. She describes how her stiffness subsides and she
began to feel less irritation in her body. Therefore she decided to
take on another job just because she was feeling so good. At the end
of the study she was getting worse again, her stomach was in bad
shape and the stiffness in her joints was back and she blamed her
condition on the new job, additional stress, heavier workloads and
wrong diet.
Connie had chronic pain in her neck, and shoulders while
experiencing numbness in her arms. In the last few months before
the study, her condition has gotten increasingly worse. As shown in
the diagram of the pain during the study it was evident that after
the eighth session, things were dramatically turning better for her
(Fig. 3). At the end of the study she was feeling much better than
before the study. At about week nine she said, ‘‘This has been one of
my best weeks.’’ The numbness was less and had almost dis-
appeared from her arms; in addition, her headaches were less
frequent.
The fourth participant Donna was hit in a car accident and
experienced whiplash; soon thereafter her body gradually became
worse. In her own words, she said,
‘‘I remember that at first I was very tired and had no energy and
was not able to get going. Then just very slowly, I started to
stiffen up in one area after another and couldn’t move as easily.
But this just happened very slowly after the accident over the
period of a year. It started at the back of my neck, but then
started to move down the body to my arms and down my
shoulders and then to my chest area. Now it is also in my lower
back.’’
For Donna, pain changed during the study. She acknowledged
this in her diary
‘‘The first weeks were tough, so it was an uphill battle. Then
around week seven, it started to go down again, and then I
suddenly realized that I was feeling better, both physically and
emotionally. There was less pain and better sleep and more
energy than I had before I started [the study]. It just suddenly
0
1 2 3 4 5 6 7 8 9 10 11 12 13
Week
Fig. 2. Betsy: Pain during the study.
occurred to me. I was going over my diary and making sure that I
had everything there, and then suddenly I noticed VOW!! And it
kept on being that way. I mean, with having Fibromyalgia and all
that, I would be happy if I could just be in this place and not go
downhill again.’’
She also stated that during the study when she was overloaded
with work and stress, she was in much better shape to deal with it and
concentrate on it, despite being tired. The week between sessions
eight and nine were the best for Donna in a long time (Fig. 4).
Ella experienced pain in her back and at the back of head that
bothers her everyday and frequently gets migraine headaches. She
stated that her symptoms started to appear some fifteen years ago
after the car accident. During the study it is evident in the graph
from Ella that there is not much change in pain from the first to the
last sessions (Fig. 5). Over the sessions, not much progress
occurred; in fact, for the whole time Ella experienced the same pain
in the same spots throughout the study. Sometimes there was also
pain in her elbows. When asked about her migraine headaches, she
suddenly realized that they had not been bothering her for over
three months, which was a relatively long period of time. In fact,
her headaches had not bothered her since starting her reflexology
sessions. At the beginning of the study Ella took on a new job which
became a more increased workload than expected. Although she
did not express any changes during the study she comments on
how despite her workload she felt better than expected.
Fanny has a long story of pain and chronic fatigue. The pain is all
over the body and she describes it as heavy burdensome sore and
overwhelming in her head, shoulders, back and arms. In summary,
the reflexology sessions did not do much for Fanny. After the study
started, there were some changes and benefits that came and went
quickly. She noticed some relief of the ‘‘helmet’’ on her head and
some lightness in other areas. However, this relief never lasted long

Pain level Pain level

10 10
9 9
8 8
7 7
6 6
5 5
4 4
3 3
2 2
1 1
0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4 5 6 7 8 9 10 11 12 13
Week Week

Fig. 1. Anna: Pain during the study. Fig. 3. Connie: Pain during the study.
170 T.J. Gunnarsdottir, C. Peden-McAlpine / Complementary Therapies in Clinical Practice 16 (2010) 167–172

Pain level Pain level

10 10
9
9
8
8
7
7
6
6 5
5 4
4 3
3 2
2 1
1 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
0
1 2 3 4 5 6 7 8 9 10 11 12 13
Fig. 6. Fanny: Pain during the study.
Week

Fig. 4. Donna: Pain during the study.

enough, and usually not throughout the day of the session. All
activities during the day affected her wellbeing. If she felt better
after a session, the benefits would disappear while she drove home
because merely driving a car increased her pain. It was obvious that
her condition was very severe and reflexology did not have much to
offer to her. The reason for her graph being different is due to the
aggressiveness of the pain which was constantly fluctuating each
day (Fig. 6).
5.2. Cross-case analysis
Although the women had different stories to tell, they all
seemed to have suffered from an accident or shock, or some trau-
matic experience that they identified as a starting point of their FM.
Pain was sensed the most prominent symptom the women sense as
a part of FM. They described their pain starting in isolated areas,
then traveling from one area to another. Some women remembered
how the pain progressed by starting in one area in the body, then
beginning to show up in other areas, until the entire body had
somehow become affected. The pain was felt mostly in the joints
and muscles, but was described as different from muscle soreness.
Some painful areas responded to better to reflexology, such as
headaches, pain in shoulders, arms and the neck, as evident by
lessening pain strength or the pain disappearing. At specific sites,
the pain remained in the joints, the fingers, or the coccyx,
depending on each individual. However at most of those sites the
level of pain decreased during the study.
The pain is also described in the graphs of pain as drawn by the
women in each case. The graphs were verified with their diaries to
make sure that what they had reflected in writing was corroborated
by the figure above. When examining the lines in the graphs, the
subjects who showed decreased pain on the graph all started to get
Pain level
10
9
8
7
6
5
4
3
2
1
0
1 2 3 4 5 6 7 8 9 10 11
Week
Fig. 5. Ella: Pain during the study.
worse first. For most of them, this worsening was immediately after
the first session, while for others, it was an ongoing experience, up
to the seventh session. They described their condition as either
being worse in pain or feeling worse in their body. There were
times when some considered withdrawing from the study but
decided to hang on and see what happened. It is interesting to see
that at approximately the sixth to eighth weeks, four of the six
women started to show dramatic changes in their wellbeing and
felt much better rather suddenly during the eighth and ninth
weeks.
Sleep disturbance is a symptom frequently seen in FM. There-
fore, a specific section in the diary was used to record the partici-
pants’ sleep patterns for each day. They described their sleep as not
being enough, as waking up without feeling adequately rested and
as awakening with stiffness and pain. At the end of the study, the
patterns of sleep did not change much for any of the participants.
Their sleep rhythms were similar throughout the study, and they
interpreted these rhythms as ‘‘not good enough.’’ The findings in
each case indicated that the quality of sleep depended more on
what was happening in their lives rather than on the disease itself.
The most significant factors affecting their sleep were disturbances
by children, their work schedule, stress or keeping themselves
occupied instead of going to bed.
Some other health problems or FM symptoms responded to the
reflexology. This finding was evident for migraine headaches,
edema, and fecal elimination problems. Migraine headaches, which
were a common problem for two of the participants, did not
happen during the study. Also, if a women had the tendency to get
edema in their legs or other areas, then this commonly decreased
during the study period. However, these effects did not last long
after the study period; moreover, their edema often fluctuated
along with the women’s menstrual cycles, becoming worse the
week before menstruation. Fecal elimination became more normal
for some, and they described their stools becoming looser and more
frequent.
Events going on in their lives definitely affected the way they felt
during the study. All but one of the participants was working
outside the home, and their work affected their FM symptoms.
However, it was interesting that several of the women reported that
they were able to take on more responsibilities or were able to
increase their workload during the study period. Five of the women
talked about how they did not feel as tired as they had before the
study started; indeed, they did not feel as ‘‘loaded’’ with their
symptoms, even though their workloads or stressors had increased.
Three participants (Anna, Connie and Donna) detected benefits
after the first few sessions, which seemed to increase their control
over their FM symptoms, enabling them to cope better. That
sentiment lasted throughout the study for these three participants.
12 13 Two of the women (Betsy and Ella) began new jobs during the
study period. At the end of the study they alluded to how that
workload affected their symptoms and wellbeing and increased
their stress seriously. Betsy showed improved wellbeing at first, but
 T.J. Gunnarsdottir, C. Peden-McAlpine / Complementary Therapies in Clinical Practice 16 (2010) 167–172
her condition worsened as her workload and stress increased. Ella’s
status did not change over the study period, showing also that she
did not get any worse. She also described how frustrating it was not
to find any benefits from the reflexology and lost interest in what
was going on in the sessions over time. For the sixth participant
(Fanny), it was obvious right at the beginning that her symptoms
were very serious, and her entire days had to be scheduled around
her pain. It was difficult for her to add the sessions to her schedule,
as she already had other appointments during the week. Although
she could relax during most of the sessions, the reflexology effects
had completely disappeared on the way home, just by stress from
driving or because the weather was cold.
6. Discussion
The study findings demonstrated that pain was the most prev-
alent symptom and was evident by how the women recorded their
pain each day in their diaries and how they were feeling at different
sites in their bodies during the day. The pain was sensed as more
severe than muscle soreness, although it was mostly sensed in the
muscles and joints. The women described the pain as all over, sore,
numb, aching and hurting; they narrated how it was always
present, constant and wandering from one location to another,
similar to previously documented fibromyalgia pain24 and as both
mental and physical.25 The pain changed during the study and
started to become more isolated and decreased in severity in four
out of six cases. The areas that responded best were the head,
shoulders, neck and arms. This phenomenon was most evident
after the seventh or eighth sessions, indicating that several sessions
of reflexology are needed in order to show evidence of lasting
benefits.
The findings demonstrated that the participants experienced
some pain relief that increased their wellbeing. Pain at specific sites
decreased, especially headaches and migraine headaches. This
result reflects findings from two other studies of reflexology, in
which patients described less pain following reflexology.18,26 In
general, pain in some areas did not change during this study; for
example, pain in joints. It may have been that they had become too
chronic or needed more reflexology sessions in order to have any
effect. Benefits of reflexology for other symptoms such as edema
and fecal elimination have been reported before.17 Looking at the
figures of pain for each participant it is interesting that before the
women got better they got worse. This may be a factor in healing
and needs to be analyzed further.
The findings supported the theoretical framework behind
reflexology, which aims to heal and to restore balance and whole-
ness. When the women felt the process of recovery and repair take
place, they felt more whole and gained a better sense of coherence.
In four cases, the pain decreased in specific places. These
phenomena took place as the women started showing dramatic
changes between the sixth to eighth sessions. In the study by
Launsö et al.,18 in depth interviews were conducted with 10 of the
participants. The analysis of the interviews demonstrated that
patients who considered themselves cured based this on their
involvement with reflexology and the fact that they did a lot of
thinking about their health and their understanding of the head-
ache changed. They recognized the headache as part of the body
and therefore related to a mind–body connection.
The women were all eager to try reflexology, as they had
previously been trying other CATs to relief symptoms. They
described how they felt they needed to take more control of their
lives in order to change their situations. However, they also
acknowledged that they discovered that they had not prioritized
their lives and routines around themselves. In fact, their families
and work came first. If something was to change, they needed to
171
care for themselves, move on and learn to live again. This pattern
was also shown in other studies of women with FM.27,25,24,28,29
There is a growing amount of literature on the efficacy of CAT;
nevertheless, more is needed to understand the therapies in order
to build up evidence-based literature for their use.30 Unfortunately,
the research activity in complementary medicine is lacking in
funding, training and expertise in research methodologies, along
with a lack of interest among experienced researchers and inade-
quate tools to measure outcomes in complementary medicine.31
Currently most research on the efficacy of CATs is focused on
using quantitative methods, which strip important aspects of lived
experience from such studies. Nurses are in a primary position to
conduct research on reflexology, in that their holistic background is
in tune with the philosophies behind reflexology. Before reflex-
ology is to be used within hospital settings to benefit patients, more
empirical research evidence is needed to support its use.
7. Conclusions
Reflexology may help to decrease the experience of pain in
patients with FM. The findings of this study demonstrate that the
multiple case study analysis used gives reflexology research a new
insights into the experience of FM. Therefore, an increased use of
qualitative approaches in researching complementary and alter-
native therapies is recommended. By adding qualitative research
methods to researching complementary therapies, an increased
understanding of CATs can be greatly enhanced. The disadvantage
of the multiple case study approach for this study was that it is
focused only on six cases, thereby limiting the transferability of the
findings to other populations.
Health care providers help their patients to deal with their
symptoms, such as pain and discomfort. In addition, they care
about healing, alleviating health problems, and managing symp-
toms. Reflexology and other CATs may offer important tools to
increase the healing mechanisms in their patients. Reflexology can
be a prime tool to provide caring, presence showing compassion in
combination with a feeling of doing something that may help
a patient to become more whole and feel better.
Acknowledgments
The research reported here was supported by The Icelandic
Centre for Research (Rannis). Icelandic Nurse’s Association, The
Nursing Research Institute at the Faculty of Nursing and Minning
Margretar.
References
1. Wolfe F. Development of criteria for the diagnosis of fibrosistitis. American
Journal of Medicine 1986;81:99–106.
2. Boissevain MD, McCain GA. Toward an integrated understanding of fibro-
myalgia syndrome. II. Psychological and phenomenological aspects. Pain
1991;45:239–48.
3. Bengtsson A, Henriksson KG. The muscle in fibromyalgia: a review of Swedish
studies. Journal of Rheumatology 1989;16:144–9.
4. Dimmock S, Troughton PR, Bird HA. Factors predisposing to the resort of
complementary therapies in patients with fibromyalgia. Clinical Rheumatology
1996;15:478–82.
5. Carette S, McCain GA, Bell DA, Fam AG. Evaluation of amitriptyline in primary
fibrositis: a double-blind, placebo-controlled study. Arthritis Rheumatica
1986;29:655–9.
6. Burckhardt CS, Mannerkorpi K, Hedenberg L, Bjelle A. A randomized, controlled
clinical trial of education and physical training for women with fibromyalgia.
Journal of Rheumatology 1994;21:714–20.
7. Haanen HC, Hoenderdos HT, van Romunde LK, Hop WC, Mallee C, Terwiel JP,
et al. Controlled trial of hypnotherapy in the treatment of refractory fibro-
myalgia. Journal of Rheumatology 1991;18:72–5.
8. Sim J, Adams N. Systematic review of randomized controlled trials of non-
pharmacological interventions for fibromyalgia. The Clinical Journal of Pain
2002;18(5):324–36.
172 T.J. Gunnarsdottir, C. Peden-McAlpine / Complementary Therapies in Clinical Practice 16 (2010) 167–172
9. Nicassio PM, Schuman C, Kim J, Cordova A, Weisman MH. Psychosocial factors
associated with complementary treatment use in fibromyalgia. Journal of
Rheumatology 1997;24:2008–13.
10. Pioro-Boisset M, Esdaile JM, Fitzcharles MA. Alternative medicine use in
fibromyalgia syndrome. Arthritis Care Research 1996;24:937–40.
11. Dougans I. The complete illustrated guide to reflexology. Boston: Element Books;
1999.
12. Tiran D. Reviewing theories and origins. In: Mackereth PA, Tiran D, editors.
Clinical reflexology. Edinburgh: Churchill Livingstone; 2002. p. 5–15.
13. Gunnarsdottir TJ. Reflexology. In: Snyder M, Lindquist R, editors. Complemen-
tary & alternative therapies in nursing. New York: Springer Publishing Company;
2010. p. 307–20.
14. Ingham ED. Stories the feet can tell thru reflexology/stories the feet have told thru
reflexology. Saint Petersburg, FL: Ingham Publishing; 1984.
15. Stephenson LN, Weinrich SP, Tavakoli AS. The effects of foot reflexology on
anxiety and pain in patients with breast and lung cancer. Oncology Nursing
Forum 2000;27(1):67–72.
16. Hodgson H. Does reflexology impact on cancer patients’ quality of life? Nursing
Standard 2000;14(31):33–8.
17. Joyce M, Richardson R. Reflexology can help MS. International Journal of Alter-
native and Complementary Medicine 1997;July:10–2.
18. Launsö L, Brendstrup E, Arnberg S. An exploratory study of reflexological
treatment for headache. Alternative Therapies in Health and Medicine
1999;5(3):57–65.
19. Siev-Ner I, Gamus D, Lerner-Geva L, Achiron A. Reflexology treatment relieves
symptoms of multiple sclerosis: a randomized controlled study. Multiple Scle-
rosis 2003;9:356–61.
20. Mackereth PA, Booth K, Hillier VF, Caress A. Reflexology and progressive muscle
relaxation training for people with multiple sclerosis: a crossover trial.
Complementary Therapies in Clinical Practice 2009;15:14–21.
21. Wang M, Tsai P, Lee P, Chang W, Yang C. The efficacy of reflexology: a systematic
review. Journal of Advanced Nursing 2008;62(5):512–20.
22. Gunnarsdottir TJ, Jonsdottir H. Does the experimental design capture the
effects of complementary therapy? A pilot study using reflexology for patients
undergoing coronary artery bypass graft surgery. Journal of Clinical Nursing
2007;16:777–85.
23. Stake RE. Multiple case study analysis. New York: Guilford Publications; 2006.
24. Söderberg S, Norberg A. Metaphorical pain language among fibromyalgia
patients. Scandinavian Journal of Caring Science 1995;9:55–9.
25. Schaefer KM. Health patterns of women with fibromyalgia. Journal of Advanced
Nursing 1997;26(3):565–71.
26. Stephenson N, Dalton JA, Carlson J. The effect of foot reflexology on pain in
patients with metastatic cancer. Applied Nursing Research 2003;16(4):284–6.
27. Schaefer KM. Struggling to maintain balance: a study of women living with
fibromyalgia. Journal of Advanced Nursing 1995;21(1):95–102.
28. Söderberg S, Lundman B, Norberg A. The meaning of fatigue and tiredness as
narrated by women with fibromyalgia and healthy women. Journal of Clinical
Nursing 2002;11:247–55.
29. Råheim M, Håland W. Lived experience of chronic pain and fibromyalgia:
women’s stories from daily life. Qualitative Health Research 2006;16:741–61.
30. Snyder M, Lindquist R. Complementary & alternative therapies in nursing. 6th ed.
New York: Springer Publishing Company; 2010.
31. House of Lords. Selected committee on science and technology. Complementary and
alternative medicine. London: The Stationery Office; 2000.