Accepted Manuscript

The effect of foot reflexology and back massage on hemodialysis patients' fatigue and
sleep quality

Kevser Sevgi Unal, Reva Balci Akpinar

PII: S1744-3881(16)30049-4
DOI: 10.1016/j.ctcp.2016.06.004
Reference: CTCP 665

To appear in: Complementary Therapies in Clinical Practice

Received Date: 5 April 2016

Revised Date: 15 June 2016
Accepted Date: 15 June 2016

Please cite this article as: Unal KS, Balci Akpinar R, The effect of foot reflexology and back massage on
hemodialysis patients' fatigue and sleep quality, Complementary Therapies in Clinical Practice (2016),
doi: 10.1016/j.ctcp.2016.06.004.

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TITLE PAGE

THE EFFECT OF FOOT REFLEXOLOGY AND BACK MASSAGE ON

HEMODIALYSIS PATIENTS’ FATIGUE AND SLEEP QUALITY

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Running Head: Reflexology and back massage for fatigue and sleep

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Kevser Sevgi UNAL
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Osmaniye Korkut Ata University, School of Health, Osmaniye/TURKEY
Phone: +90 442 2312214
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E-mail address: Kevser-Sevgi@hotmail.com

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Reva BALCI AKPINAR *

Atatürk University, Faculty of Health Sciences, Erzurum / TURKEY

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Phone: +90 442 2312214

Fax : +90 442 2360969
E-mail address: reva@atauni.edu.tr
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ABSTRACT

Objective: The aim of this study is to examine the effectiveness of foot reflexology and

back massage on optimizing the sleep quality and reducing the fatigue of hemodialysis

patients.

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Methods: The study includes 105 volunteer patients who were registered at a private

dialysis clinic and were receiving hemodialysis treatment. Foot reflexology and back

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massage were administered to the patients two times a week for four weeks. The Visual

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Analogue Scale for Fatigue and the Pittsburg Sleep Quality Index were used to collect

data.

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Results: The differences between the pretest and posttest score averages of the patients on
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the Visual Analogue Scale for Fatigue and the Pittsburg Sleep Quality Index were

statistically significant (p<0.001).

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Conclusion: Foot reflexology and back massage were shown to improve the sleep quality
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and reduce the fatigue of hemodialysis patients. Compared to back massage, foot
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reflexology was determined to be more effective.

Keywords: back massage, fatigue, hemodialysis, nursing, foot reflexology, sleep quality
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1. Introduction
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Hemodialysis patients experience fatigue due to a variety of reasons, including the

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accumulation of metabolic waste in the body, fluid-electrolyte imbalances, abnormal

energy expenditure, inappetence, anemia and depression. As this feeling of fatigue tends to

persist even after resting and is difficult to prevent. Fatigue and sleeplessness negatively

affect patients' work, leisure activities, nutritional habits, sexual lives and relationships

with family and friends [1-4]. It has been reported that between 50% and 83% of
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hemodialysis patients experience sleep disorders [1,2], and that between 7% and 92.5%

experience fatigue [1,3,4].

Controlling the sleeplessness and fatigue experienced by hemodialysis patients

requires a multidisciplinary approach, one in which nurses play a particularly important

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role in eliminating or mitigating these complaints. Included among the complementary

practices nurses use to overcome problems with sleeplessness and fatigue are massage,

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aromatherapy and music therapy [5]. Massage is included in the Nursing Intervention

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Classification and is a simple and noninvasive method for ensuring relaxation [5].

Involving the palpation of soft tissue and muscles, massage is therapeutic touch that leads

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to both physical and mental relaxation and is capable of generating energy transmission
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between the practitioner and the subject, and therefore can be used to help patients

overcome sleep problems [6,7]. Field et al. (2007) reported that back massage resulted in
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reduced pain, anxiety and sleep disorders and improved their participants' moods by
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relaxing them [8].

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Reflexology is defined as: “A technique for helping to normalize body functions by

applying the hands to reflex points in the hands, feet and ears that are related to the entire
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body’s glands, organs and parts” [9-11]. In reflexology, which is the stimulation of neural

pathways, reflex areas are stimulated using the fingers in order to transmit nerve impulses,
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restore proper flow of the blood stream and maintain the homeostasis of the body. More
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particularly, foot reflexology is a pressure technique applied to the nerve endings in feet.

The effects of reflexology on subjects have been demonstrated in various clinical trials

[11-14,16-24,25]. Studies have shown that reflexology reduces anxiety [12], nausea and

vomiting [16,23], pain [17,18,24], sleeplessness [17,18,21] and fatigue [18-20,22-24]. In

one particular study conducted on patients with chronic renal failure and hemodialysis

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patients, reflexology was shown to have positive effects on cramps, fatigue, emotions and

the immune system [20]. In the literature review, no studies, however, were found that

compare the effects of foot reflexology and back massage on hemodialysis patients.

This study, therefore, analyzes the effects of foot reflexology and back massage on

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the fatigue and sleep quality of hemodialysis patients.

2. Methodology

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The data for this randomized, controlled, experimental study were collected

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between January, 2014 and February, 2015.

2.1. Population

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The study population consisted of 200 patients registered at a private dialysis center
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in Turkey. Of these 200 patients, 90 were excluded from the study for failure to meet the

inclusion criteria, leaving 110 patients for participation in the study. The patients were
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randomly assigned to three groups: the foot reflexology group (n=36), the back massage
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group (n=37) and the control group (n=37). From the 110 patients, a total of 105 patients
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(35 patients per group) reached the end of the study, with one patient in the foot

reflexology group and two patients in the back massage group having withdrawn from the
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study, and two patients in the control group having left the dialysis center.

2.2. Inclusion Criteria

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The inclusion criteria for participation in the study involved patients between the
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ages of 18 and 60 who received hemodialysis therapy twice a week, who did not have any

communication problems.

2.3. Exclusion Criteria

Patients with skin lesions, open foot wounds, malignant diseases, thrombosis, or

bleeding disorders were excluded from the study [9,10,26,27].

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2.4. Data Collection Tools

Demographic data were collected with a Patient Information Form, which included

input on the age, gender and other features related to the patient, the Visual Analogue

Scale for Fatigue (VASF) and the Pittsburg Sleep Quality Index (PSQI).

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VASF: This scale, developed by Lee et al. (1991), features 18 items. The 1st, 2nd,

3rd, 4th, 5th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, and 18th items form the fatigue

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subscale, while the 6th, 7th, 8th, 9th, and 10th items form the energy subscale [28]. The

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scale uses a 10 centimeter line, where extremely positive statements constitute one end and

extremely negative statements the other end. The most positive and negative statements on

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the fatigue subscale are scored 0 and 10, respectively, with the reverse being true for the
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energy subscale. In other words, the items on the fatigue subscale and the energy subscale

are ordered from the most positive to the most negative and vice versa, respectively. A
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high score on the fatigue subscale and a low score on the energy subscale indicate severe

fatigue. The VASF scale was translated into Turkish by Yurtsever and Bedük in 2003 [3].
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In the Turkish version, the Cronbach's α internal consistency coefficient was found to be

0.90 for the fatigue subscale and 0.74 for the energy subscale [3].
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PSQI: The PSQI, developed by Buysse et al. (1989), is used to evaluate sleep

quality [29]. Answers to this scale are made according to the patient’s sleeping experience
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within the last month. The scale comprises 19 self-rated questions, and these 19 items are
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grouped into 7 component scores (Subjective Sleep Quality, Sleep Latency, Sleep

Duration, Sleep Efficiency, Sleep Disturbance, Hypnotic Medication Use, Daytime

Dysfunction). Each item is given a score between 0 and 3, and the total score on the 7

subscales yields the PSQI score. Total PSQI scores range between 0 and 21, where a PSQI

score higher than 5 indicates poor sleep quality. The reliability coefficient of the original

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scale is 0.83 [29], while the scale translated into Turkish by Ağargün et al. (1996) has a

Cronbach's alpha reliability coefficient of 0.80 [30].

2.5. Intervention

The VASF and the PSQI were administered to the patients as a pretest immediately

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before they were taken to hemodialysis. Foot reflexology, back massage and tests were

administered by the researcher in a 22°C, completely quiet room, which was equipped with

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an examination couch to conduct the massages.

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The foot reflexology group was given foot reflexology two days a week for four

weeks (a total of 8 sessions). The patients were first asked to remove their socks (if any)

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and then placed in either sitting or lying position, before proceeding to administration of
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foot reflexology for 30 minutes, 15 minutes for each foot. Three to five drops of baby oil

were applied at room temperature to facilitate the massage [9,10].

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Particular attention should be given to avoiding applying the baby oil in large
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amounts, as it is thought to decrease the amount of pressure. Foot reflexology begins with
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relaxation exercises, which involve thumb, finger and squeezing movements and rubbing

and patting actions. The application of foot reflexology is performed in a top to down
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manner, where the actual massage starts on the pituitary gland, hypothalamus, brain and

pineal body points of the big toe, followed by massage on the medulla spinalis body point,
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which is located on the area stretching from the big toe to the middle of the back side of
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the heel. Pressure is then applied to the solar plexus, after which reflexology techniques are

applied to all of the areas corresponding to the nerve projections on the feet. The foot

reflexology ends with the performance of the same relaxation exercises mentioned above

[9,10].

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The back massage group was given back massages two days a week for four weeks

(a total of 8 sessions). The patients were asked to lie down on whichever side they felt

most comfortable and were then given a back massage for 30 minutes. Three to five drops

of baby oil, applied at room temperature, were used to reduce friction during the massage.

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The effleurage, petrissage and friction styles of massage were performed [27].

After completion of the back massage and foot reflexology sessions, the VASF and

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the PSQI were administered to both groups as a posttest. The control group did not receive

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foot reflexology or back massage but was administered the posttest at the end of the fourth

week. Foot reflexology, back massage and tests were administered before the patients were

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taken to hemodialysis (Figure 1).
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2.6. Data Analysis

The statistical analyses were performed with SPSS for Windows. Averages and
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percentages were used for analysis of descriptive features, while the t-test was performed
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for dependent groups in intragroup comparisons and the ANOVA for intergroup
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comparisons.

Ethical Considerations
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The approval of the Atatürk University Faculty of Health Sciences Ethics

Committee and the written permission of the relevant dialysis center were obtained prior to
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conducting the study. After being informed about the study, the written and oral consent of
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the patients was obtained.

3. Results

Among all the patients in the study, 47.6% were females, 52.4% were males and

their average age was 54.33±12.96. No statistically significant difference was found

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between the sociodemographic characteristics of the patients, the results of which indicate

that the groups included in the study were homogeneous (Table 1).

Table 2 shows that the pretest fatigue score averages of the foot reflexology, back

massage and control groups were 82.46±22.27, 80.31±15.74 and 74.54±22.52,

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respectively. The difference between the fatigue score averages of the groups was not

statistically significant (p>0.05). The posttest fatigue score averages of the foot

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reflexology, back massage and control groups were 58.51±18.81, 70.77±16.05, and

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80.74±21.11, respectively. The differences between the posttest fatigue score averages and

between the pretest and posttest fatigue score averages of the groups were statistically

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significant (p<0.001).
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The pretest energy score averages of the foot reflexology, back massage and

control groups were 21.37±9.05, 22.63±7.55 and 24.97±7.99, respectively. The difference
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between these averages was not statistically significant (p>0.05). The posttest energy score
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averages of the foot reflexology, back massage and control groups were 28.74±6.67,

24.20±7.35 and 21.97±7.98, respectively. The difference between these averages was
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statistically significant (p>0.001). The intragroup comparison of the pretest and posttest
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score averages showed a statistically significant difference in the foot reflexology group

(p<0.001), back massage group (p<0.05) and control group (p<0.05) (Table 2).
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The PSQI pretest score averages of the foot reflexology, back massage and control
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groups were 11.09±3.18, 10.59±2.11, 9.20±2.42, respectively, while the PSQI posttest

score averages of these groups were 5.54±2.15, 8.34±2.39 and 11.8±2.47, respectively.

The difference between the PSQI pretest and posttest score averages within the groups and

the difference between the posttest score averages of the groups were statistically

significant (p<0.001), (Table 2).

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4. Discussion

The pretest fatigue score averages of the foot reflexology, back massage and

control groups indicated that the patients had high levels of fatigue. Fatigue develops in

hemodialysis patients who have chronic renal failure due to a variety of reasons, including

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the accumulation of metabolic waste in the body, abnormal energy expenditure,

inappetence or anemia [3,4]. Yurtsever [3] found that 92.5% of hemodialysis patients

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experience fatigue. Other studies [6,31,32] conducted on this subject have also confirmed

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the experience of fatigue in these patients (Table 1).

The fact that there were no significant differences between the pretest fatigue score

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averages of the groups (p>0.05) shows that the groups’ fatigue levels were homogeneous.
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The lower posttest score average of the foot reflexology group on fatigue and energy

suggests that foot reflexology reduced their fatigue and increased their energy (p<0.001)
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(Table 2). In the study conducted by Özdemir et al. (2013), it was found that reflexology
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reduced the fatigue level of hemodialysis patients [20]. Other studies in the literature show
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that [19,22-24] reflexology also reduced fatigue in other patient groups. In the studies

conducted by Won [19] with chemotherapy patients, by Polat [22] with COPD patients, by
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Özdelikara [23] with breast cancer patients and by Doğan [24] with multiple sclerosis

patients, reflexology was found to reduce fatigue considerably. The findings of the present
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study are similar to those found in the literature [9,10,13,14,19,20,22-24].

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The posttest score average of the back massage group on fatigue and energy

suggests that back massage reduced their fatigue and increased their energy (p<0.001)

(Table 2). Back massage stimulates the receptors on the skin, relieves the muscles and

dilates arterioles, thereby relaxing tired muscles. It is well-known that massage is able to

reduce cortisol levels and to increase serotonin and dopamine levels [33]. The decrease in

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the fatigue level and the increase in the energy level of the back massage group can be

explained by the facts that dopamine increases energy levels and that serotonin promotes

relaxation. Hasankhani et al. (2013) also demonstrated that back massage reduced fatigue

in hemodialysis patients [34]. The posttest score averages of the reflexology group was

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lower in terms of fatigue and higher in terms of energy than those of the back massage

group. In addition to supporting the theories of reflexology, these findings suggest that

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reflexology reduces fatigue levels and increases energy levels more effectively than back

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massage.

The intragroup comparison of the fatigue score average of the control group

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indicated a significant increase in their fatigue score average. This shows that their fatigue
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levels were increasing over time. Moreover, previous studies [3,35,36] have shown that

quality of life fell and fatigue levels rose as the duration of dialysis increased. The present
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study found that the groups had homogeneous PSQI pretest score averages, which were
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higher than 9 for all groups (Table 2). A total score of 5 or higher on the PSQI indicates

poor sleep quality [30]. Therefore, the pretest findings revealed that the hemodialysis
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patients had poor sleep quality. The poor sleep quality of hemodialysis patients is caused
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by factors such as the limitations in life, metabolic changes resulting from the disease,

pain, diet, fatigue, cramps, metabolic acidosis, peripheral neuropathy, emotional problems
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and longer exposure to uremic toxins [37]. In patients with chronic renal failure, abnormal
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cellular interleukin production may cause somnolence, and the removal of these substances

from the body through dialysis may lead to insomnia or sleep disorders. Some studies have

indicated that patients receiving dialysis due to chronic renal failure experience more sleep

problems than healthy individuals [1,38]. Neda et al. (2005) reported that 67.7% of the

hemodialysis patients in their study had poor sleep quality [39].

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In this study, the lower score average of the foot reflexology group on the PSQI

shows that the reflexology was effective in improving sleep quality. Similar studies have

also found reflexology to significantly increase sleep quality [17,18,21]. For example,

Hughes et al. (2009) reported that the increase in the duration of patients’ sleep led to an

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increase in their perceived sleep levels [25]. The decrease in the PSQI score average of the

back massage group indicates that back massage is also effective in increasing sleep

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quality. Back massage is considered to generate a therapeutic effect on the subject and to

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reduce cortisol, norepinephrine and epinephrine levels by stimulating the sympathetic

nervous system, thereby increasing patients' sleep quality by virtue of the physical and

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psychological relaxation it provides [33]. Yaman [7] and Çınar [40] also found that back
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massages given to elderly people with poor sleep quality before they went to bed increased

their sleep quality. The PSQI posttest score average of the back massage group was lower
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than that of the control group, a finding which also serves to indicate that back massage is
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effective at increasing sleep quality. The lower PSQI posttest score average of the foot
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reflexology group than that of both the back massage group and the control group

(p<0.001) suggests that foot reflexology increases sleep quality more effectively than back
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massage (Table 2).

Limitations of the Study

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The results can only be generalized for hemodialysis patients, since this study was
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limited to this patient group alone. The study’s most significant limitation, however, is that

other factors that might affect the patients' fatigue and sleep status were not controlled.

5. Conclusion

This study has shown that both foot reflexology and back massage reduce fatigue

and increase energy levels and sleep quality. Foot reflexology, however was found to be

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more effective than back massage. It is suggested that foot reflexology be used to reduce

the fatigue and sleep problems experienced by hemodialysis patients. Back massage, which

is a simple and easily applied intervention, should also be used to reduce the fatigue and

sleep problems of hemodialysis patients.

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Conflict of interest statement

The authors have no conflict of interest to declare.

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Acknowledgments

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This research was approved as a doctoral thesis of Kevser Sevgi Unal by Ataturk

University Institute of Health Sciences and presented at the ENDA&WANS Congress held

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in Hannover, Germany between October 14-17, 2015. The authors would like to thank all
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the patients who participated in this study.

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Table 1. Sociodemographic characteristics of the patients

RG* MG* CG* Total

Characteristics X±SD X±SD X±SD X±SD Significance Test

Average Age (year) 51.74±12.29 53.89±13.18 57.37±13.12 54.33±12.96 F=1.706 p=0.187

Average Height (cm) 166.11±9.39 161.51±10.09 157.86±20.07 161.83±14.33 F=3.033 p=0.053

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Average Weight (kg) 76.29±13.95 72.91±12.80 70.40±13.62 73.20±13.55 F=1.684 p=0.191

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Gender n % n % n % n %

Female 16 45.7 19 54.3 15 42.9 50 47.6 χ2 =0.993

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Male 19 54.3 16 45.7 20 57.1 55 52.4 p=0.609

Marital Status

Married 26 74.3 27 77.1

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28 80.0 81 77.1 χ2 =1.274
AN
Single 9 25.7 8 22.9 7 20.0 24 22.8 p=0.866

* RG: Foot Reflexology Group, MG:Back Massage Group, CG:Control Group

M
D
TE
C EP
AC
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Table 2. Intragroup and intergroup comparisons of the patients' fatigue and sleep quality score

averages

RG MG CG RG-MG-CG RG-MG RG-CG MG-CG

Pretest 82.46±22.2 80.31±15.7 74.54±22.5 F=1.407 t=0.465 t=1.478 t=1.243

FATIGUE

p=0.250 p=0.643 p=0.144 p=0.218

PT
Posttest 58.51±18.8 70.77±16.0 80.74±21.1 F=12.314 t=-2,933 t=-4.651 t=-2.224

RI
p=0.000 p=0.005 p=0.000 p=0.029

p 0.000 0.000 0.026

SC
t 10.448 5.615 -2.327

Pretest 21.37±9.05 22.63±7.5 24.97±7.9 F=1.729 t=-0.631 t=-1.765 t=-1.261

U
ENERGY

p=0.183 p=0.530 p=0.082 p=0.212

AN
Posttest 28.74±6.6 24.20±7.3 21.97±7.9 F=7.709 t=2.707 t=3.852 t=1.215

p=0.001 p=0.009 p=0.000 p=0.229

M

p 0.000 0.018 0.002

t -6.256 -2.483 3.434

D

Pretest 11.09±3.18 10.59±2.11 9.20±2.42 F=5.065 t=0.619 t=2.788 t=2.735

TE

p=0.008 p=0.538 p=0.007 p=0.008

PSQI

Posttest 5.54±2.15 8.34±2.39 11.88±2.47 F=63.621 t=-5.159 t=11.38 t=-6.051

EP

p=0.000 p=0.000 p=0.000 p=0.000

C

p 0.000 0.000 0.000

AC

t 13.634 4.884 -7.234

 ACCEPTED MANUSCRIPT
Hemodialysis Patients (N=200)
Patients included in this study (n=105)

PT
Foot Reflexology Group/RG Back Massage Group/MG Control Group/CG

RI
(n: 35) (n: 35) (n: 35)

SC
Pretest

U
Patient Information Form
PSQI
AN
VASF
M
D

RG MG CG
Hemodialysis patients were Hemodialysis patients were
TE

Neither reflexology nor

given foot reflexology for 30 given back massage for 30 back massage were given.
minutes, twice a week for 4 minutes, twice a week for 4
weeks (a total of 8 sessions). weeks (a total of 8
EP

sessions).
C
AC

Posttest Posttest Posttest

(after 4 weeks) (after 4 weeks) (after 4 weeks)
PSQI PSQI PSQI
VASF VASF VASF

Figure 1. Study Scheme

 ACCEPTED MANUSCRIPT

Highlights

• The aim of this study is to examine the effectiveness of foot reflexology and back

massage at optimizing the sleep quality and reducing the fatigue of hemodialysis

patients.

PT
• Foot reflexology and back massage improved the sleep quality and reduced the

fatigue of hemodialysis patients.

RI
• Foot reflexology is more effective than back massage for sleep quality and fatigue.

U SC
AN
M
D
TE
C EP
AC