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International Journal of Nursing Practice 2013; 19: 265–273

RESEARCH PAPER

The effect of reflexology applied on

haemodialysis patients with fatigue,
pain and cramps
Gülistan Özdemir RN
Nurse, Hacı Bozan Bozanoglu Anadolu Medical School, Şanlıurfa, Turkey

Nimet Ovayolu RN PhD

Associate Professor, Faculty of Health Science, Gaziantep University, Gaziantep, Turkey

Özlem Ovayolu RN PhD

PhD Instructor, Faculty of Health Science, Gaziantep University, Gaziantep, Turkey

Accepted for publication August 2012

Özdemir G, Ovayolu N, Ovayolu Ö. International Journal of Nursing Practice 2013; 19: 265–273
The effect of reflexology applied on haemodialysis patients with fatigue, pain and cramps

The research was conducted to evaluate the effect of foot reflexology on fatigue, pain and cramps in haemodialysis patients.
The sample consisted of 80 patients in total, 40 intervention and 40 control patients, receiving treatment in the
haemodialysis units of two institutions. Data were collected by using a questionnaire, Piper Fatigue Scale and visual
analogue scale for measuring the severity of cramp and pain. The intervention group received reflexology treatment
for 1 week in three sessions following haemodialysis, each session lasting approximately 30 min. Parametric and non-
parametric tests were used in data analysis. It was determined that reflexology reduced the fatigue subscale scores and total
scale scores as well as pain and cramp mean scores in the intervention group. The research results revealed that the severity
of fatigue, pain and cramp decreased in patients receiving reflexology.
Key words: cramp, fatigue, haemodialysis, pain, reflexology.

INTRODUCTION treatment model, patients still experience some problems

In Turkey, about 60 000 patients live on dialysis, and
approximately 90% of these patients receive haemodialy-
sis treatment.1 Haemodialysis, as one of the treatments
used for renal failure, is a life-saving treatment for
patients.2–4 However, despite the advancements in this
Correspondence: Özlem Ovayolu, Department of Nursing, Faculty of
Health Science, Gaziantep University, Gaziantep 270310, Turkey.
Email: oucan@gantep.edu.tr
such as fatigue, cramp and pain, which negatively affect
their daily life and overall quality of life.5–12
Besides these frequently experienced symptoms,
haemodialysis patients are also confronted with restric-
tions in their social lives and with difficulties in pursuing
physical activities. It has been reported that especially
fatigue has an adverse effect on individuals’ work per-
formance, eating habits, sexual activities, spare time occu-
pations, joy of life and relationships with family and
friends.5,13,14 In haemodialysis patients, fatigue is observed

doi:10.1111/ijn.12066 © 2013 Wiley Publishing Asia Pty Ltd

266
to be a significant symptom with a prevalence rate of
71% (12–97%), affecting individuals’ quality of life
adversely.15–17
Pain is another symptom experienced by haemodialysis
patients. Pain is a multidimensional problem with physi-
cal, social and psychological components, and it is expe-
rienced by 50% of haemodialysis patients.7 These patients
suffer from both acute and chronic pain, and complain
especially about headache, musculoskeletal pain and
back pain.4,7,18
Cramp is defined as a sustained and involuntary muscle
contraction, and it is a painful and irritating symptom for
haemodialysis patients.3,19,20 Muscle cramps with a preva-
lence rate of 33–86% is one of the most frequent compli-
cations of haemodialysis treatment. Although the exact
cause of cramps remains unknown, it is reported to occur
mostly towards the end of dialysis and in the lower
extremities.3,21,22
The control of fatigue, pain and cramp symptoms
requires a multidisciplinary approach. It is shown in
several studies that reflexology as an alternative and com-
plementary treatment method has an important place in
the management of these symptoms, particularly in
reducing their severity.23–26 Individuals’ quality of life
improves significantly when these symptoms are effec-
tively controlled.13
Reflexology is an ancient practice. Its earliest applica-
tion was reported by the Chinese in 3000 BC.27 In health
care, reflexology is probably one of the most frequently
used complementary therapies.28 Reflexology involves
the physical act of applying pressure to all body parts,
organs and reflex points in hands and feet corresponding
to endocrine glands by using specific finger and hand
techniques.23,27–31 This method provides a physiological
relief, accelerates blood circulation and helps the body
maintain homeostasis.23,29–31 Reflexology aims to achieve
free energy flow in various organs and cells associated
with pressure points, therefore in the entire body, and
helps the body in self-improvement.23,29,31 Reflexology is
beneficial in many conditions such as pre- and postnatal
discomfort, pain, migraine and chronic obstructive
pulmonary disease. Other therapeutic effects, such as
strengthening the immune system, improving sleep
quality and wound healing, have also been claimed.
Reflexology has been offered to patients with cancer in an
attempt to improve the adverse physical and psychological
symptoms associated with the illness or its treatments.31
In the studies conducted with chronic renal failure and
© 2013 Wiley Publishing Asia Pty Ltd
G Özdemir et al.
haemodialysis patients, reflexology has been proved to be
effective on cramp, fatigue, emotional issues and immune
system.32–35 The literature survey revealed no studies con-
ducted in Turkey with regard to the effect of reflexology
on the symptoms experienced by haemodialysis patients.
Thus, this study aimed to evaluate the effect of reflexology
on fatigue, pain and cramp.
MATERIALS AND METHODS
Design and sample
The sample of this randomized, controlled and experi-
mental study consisted of a total of 80 patients, 40 inter-
vention and 40 control patients, receiving treatment in
the haemodialysis units of two institutions in the city of
Gaziantep located in the Southeastern Anatolia region of
Turkey. The number of patients included in this study’s
sample was determined by considering the analyses of a
study,32 which examined a larger sample of patients, and
by using appropriate statistical methods in line with the
opinions of specialists. Randomization was performed by
MedCalc software to give equal chance to each interven-
tion group.36 Patients included in the research were 18
years old or older; had full consciousness and orien-
tation; did not have any communication problems;
received haemodialysis three times a week; had been
receiving haemodialysis for at least 6 months; marked the
level of severity of fatigue, pain and cramp as at least 1 in
visual analogue scale (VAS); and volunteered to partici-
pate in the research. Patients with open foot wound,
suspicious fracture, burn, deep vein thrombosis and
peripheral neuropathy were excluded from the study
(n = 72).27,30
Intervention
Reflexology application was performed by a researcher
who received a certificate after completing a 30 h theo-
retical and applied education. Patients were provided
with information about reflexology prior to their enrol-
ment in the study. Foot reflexology was chosen, since all
patients had fistula arms. Reflexology was applied for
30 min in total, 15 min for each foot. Five minutes of the
15 min reflexology session were spared for relaxing tech-
niques administered at the beginning of the session; relax-
ing techniques were administered at the end of the session
for 3 min. Relaxing techniques included a back and forth
movement of the reflexologist’s palms on the outer edges
of the patient’s metatarsals, and an ankle loosening
The use of reflexology and hemodialysis
technique in which the reflexologist’s palms were used to
reflex the outer edges of the patient’s ankles. Seven
minutes were then spent for each foot for reflexing the
areas of the foot corresponding to the areas of patients’
self-reported pain and cramp and organs or body parts.27
In addition, reflexology was applied for 7 min on the
hypophysis, thyroid, parathyroid, pancreas, adrenal gland
and solar plexus points on the foot in order to control the
symptoms of fatigue, pain and cramp. During the reflex-
ology application, the patient’s neck, waist and knees
were supported in half-sitting position. Feet were posi-
tioned at the chest level of the refloxologist.23,29 In this
study, five pressing techniques—thumb pressing, finger
pressing, rubbing, stroking and squeezing—were used in
reflexology application, and pressure force was adjusted
according to the patient’s physical appearance and
age.23,29,31,37
Instrument
The data of the intervention and control groups were
collected by using the questionnaire, Piper Fatigue Scale
and VAS. Sociodemographic data were collected from
the patients, and laboratory data were obtained from the
medical records. The questionnaire included sociodemo-
graphic characteristics (age, gender, education), informa-
tion about haemodialysis treatment that could affect
fatigue (treatment period, haemoglobin, haematocrit,
albumin, urea reduction ratio (URR), dialytic clearance
(Kt/V) values) and individual information (diet compli-
ance, smoking). In the research, normal value limits were
determined as ⱖ 4 g/dL for serum albumin, ⱖ 70% for
URR, ⱖ 1.3 for Kt/V, 12.00–16.00 g/dL for haemo-
globin in women and 14.00–18.00 g/dL in men, and
37–42% for haematocrit in women and 42–52% in
men.3,4
The severity of fatigue was evaluated by the Piper
Fatigue Scale. This scale was developed by Piper et al.,38,39
and its validity and reliability study for the Turkish society
was carried out by Can.40 The scale consisted of 22 items,
all of which were measured on a 0–10 numeric rating
scale (minimum–maximum fatigue). The subjective
fatigue perception of the patient was assessed by four
domains: ‘behavioural/severity’ domain, which measured
the effect of fatigue on daily life activities and its severity;
‘affective meaning’ domain, which evaluated the emo-
tional meaning attributed to fatigue; ‘sensory’ domain,
which reflected the mental, physical and emotional symp-
toms of fatigue; and ‘cognitive/mood’ domain, which
267
measured the effect of fatigue on cognitive functions and
mood. Higher scores obtained from this scale indicated
higher levels of fatigue severity.38–40
In the study, pain and cramp were assessed by VAS on
which numbers from 0 to 10 were placed at equal inter-
vals on a 10 cm horizontal line. The patients were asked
to mark the number that reflected their pain and cramp
severity, where ‘0’ indicated the absence of pain and
cramp and ‘10’ indicated the presence of very severe pain
and cramp.
The questionnaire, Piper Fatigue Scale and VAS used
for measuring the severity of cramp and pain were applied
approximately 10 min after the first haemodialysis session
to all the patients included in the study. After the data
were collected, reflexology was applied to the interven-
tion group for a mean duration of 30 min. Following
three reflexology sessions performed in this group for a
duration of 1 week, the questionnaire, Piper Fatigue Scale
and VAS were reapplied to the intervention and control
groups approximately 10 min after the third haemodialy-
sis treatment.
Ethical consideration
Before the initiation of the applications, informed
consent was obtained from the patients receiving hae-
modialysis treatment in two institutions in Gaziantep,
and ethical committee approval was received from the
Ethics Committee of Gaziantep University, Faculty of
Medicine.
Data analysis
Descriptive statistics were reported as frequencies,
means and standard deviations, medians and ranges. Chi-
square analysis was used for sociodemographic and indi-
vidual characteristics (age, gender, educational status,
duration of haemodialysis treatment, diet compliance
and smoking) to determine the relationship between
control and experimental groups. Student t-test was
used for specific parameters of biochemistry and haemo-
dialysis (haemoglobin, haematocrit, albumin, URR,
Kt/V). Student’s t-test, one–way ANOVA, Mann–
Whitney U-test and Kruskal–Wallis test were used for
establishing specific characteristics, as well as the rela-
tionship between mean scores of fatigue, pain and cramp
before reflexology. Independent sample t-test was used
for determining pre- and postreflexology mean scores
for fatigue, pain and cramp in the intervention and
© 2013 Wiley Publishing Asia Pty Ltd
268 G Özdemir et al.

Table 1 Distribution of study participants based on their sociodemographic and individual characteristics

Characteristics Control (n = 40) Experimental (n = 40) P

n % n %

Age
18–32 years 2 5.0 10 25.0 P = 0.270
33–47 years 7 17.5 11 27.5
48–62 years 22 55.0 14 35.0
ⱕ 63 years 9 22.5 5 12.5
Age average 54.0 ⫾ 12.8 43.1 ⫾ 15.8
Gender
Female 23 57.5 27 67.5 P = 0.244
Male 17 42.5 13 32.5
Educational status
Illiterate 15 37.5 14 35.0 P = 0.721
Literate 6 15.0 4 10.0
Primary school 19 47.5 22 55.0
Duration of haemodialysis treatment
Less than 1 year 7 17.5 3 7.5 P = 0.196
1–5 years 22 55.0 19 47.5
6–10 years 8 20.0 16 40.0
ⱕ 11 years 3 7.5 2 5.0
Diet compliance
Yes 16 40.0 10 25.0 P = 0.116
No 24 60.0 30 75.0
Smoking
Yes 4 10.0 9 22.5 P = 0.112
No 36 90.0 31 77.5

control groups. Statistical significant levels were set at
P < 0.05.
RESULTS
Sociodemographic and individual
characteristics of patients
The average age of the patients in the control group was
54.0 ⫾ 12.8 years; 57.5% were female and 42.5% were
male. The average age of the patients in the intervention
group was 43.1 ⫾ 15.8 years; 67.5% were female and
32.5% were male. No statistically significant difference
was found between intervention and control groups with
regard to age, gender and education status (P > 0.05).
Haemodialysis duration varied between 1 and 5 years for
most of the patients; and according to their own state-
ments, they did not comply with their diet and did not
smoke (P > 0.05) (Table 1).
Findings for specific biochemical and
haemodialysis values that could affect
fatigue in the intervention and
control groups
No significant difference was detected between the
patients in the control and intervention groups with
regard to haemoglobin, haematocrit, albumin, URR and
Kt/V-values (P > 0.05) (Table 2).
Findings on the relationship between
specific characteristics of the patients
included in the study and
pre-reflexology mean scores of
fatigue, pain and cramp
In both groups, women experienced fatigue, pain and
cramp more intensively compared with men (P < 0.05).
Fatigue severity was observed to increase by age

© 2013 Wiley Publishing Asia Pty Ltd

The use of reflexology and hemodialysis
Table 2 Comparison of the averages of specific biochemical and haemodialysis values in the experiment and control groups that may affect
fatigue
Group Parameters
Haemoglobin Haematocrit
X ⫾ SD X ⫾ SD
Experimental 11.6 ⫾ 1.64 34.9 ⫾ 5.04
Control 11.9 ⫾ 1.67 35.7 ⫾ 5.20
P = 0.903 P = 0.944
(P < 0.05), but there was no statistically significant differ-
ence in pain and cramp severity (P > 0.05). Patients with
lower albumin levels experienced more fatigue and pain
(P < 0.05), and no relationship was found between the
mean fatigue and pain scores and haemodialysis treatment
period, URR, haemoglobin and haematocrit levels
(P > 0.05). On the other hand, patients with lower Kt/V
levels experienced more intense pain (P < 0.05). There
was no relationship between mean cramp scores and the
duration of haemodialysis treatment, URR, Kt/V and
haemoglobin levels (P > 0.05), while patients with lower
haematocrit levels were observed to experience more
cramps (P < 0.05) (Table 3).
Findings on pre- and postreflexology
mean fatigue scores of patients in the
intervention and control groups
The pre- and postreflexology mean fatigue subscale
scores of intervention patients were found to be 5.7 ⫾
1.7, 3.5 ⫾ 1.4, respectively, for ‘behavioural/severity’
domain; 5.6 ⫾ 1.7, 3.3 ⫾ 1.4, respectively, for ‘affec-
tive meaning’ domain; 5.8 ⫾ 1.7, 3.5 ⫾ 1.7, respec-
tively, for ‘sensory’ domain; and 4.3 ⫾ 1.5, 2.9 ⫾ 1.3,
respectively, for ‘cognitive/mood’ domain; and the total
mean fatigue score was determined as 5.3 ⫾ 1.5,
3.3 ⫾ 1.4, respectively.
The pre- and postreflexology mean fatigue subscale
scores of control patients were found to be 5.9 ⫾ 1.9,
5.8 ⫾ 1.8, respectively, for ‘behavioural/severity’
domain; 5.9 ⫾ 1.8, 6.1 ⫾ 1.8, respectively, for ‘affec-
tive meaning’ domain; 5.8 ⫾ 1.7, 6.0 ⫾ 1.5, respec-
tively, for ‘sensory’ domain; and 4.5 ⫾ 1.6, 4.4 ⫾ 1.6,
respectively, for ‘cognitive/mood’ domain; and the total
mean fatigue score was determined as 5.5 ⫾ 1.6, 5.5 ⫾
1.5, respectively. There was no statistically significant
269
Albumin URR Kt/V
X ⫾ SD X ⫾ SD X ⫾ SD
3.7 ⫾ 0.40 72.9 ⫾ 6.02 1.6 ⫾ 0.18
3.7 ⫾ 0.51 70.6 ⫾ 8.57 1.4 ⫾ 0.31
P = 0.167 P = 0.158 P = 0.063
difference between the intervention and control groups in
terms of pre-reflexology total mean fatigue scores and
mean fatigue subscale scores (P > 0.05); whereas, a highly
significant difference was found between the two groups
after reflexology application, and a distinctive decrease
was observed in the fatigue levels of patients in the
experimental group (P < 0.001) (Table 4).
Findings on pre- and postreflexology
pain and cramp severity mean scores of
patients in the intervention and
control groups
In the intervention group, the mean pain score decreased
from 4.4 ⫾ 1.1 to 1.6 ⫾ 1.7, and the mean cramp score
decreased from 3.4 ⫾ 2.3 to 1.1 ⫾ 1.8 after reflexol-
ogy. In the control group, on the other hand, the mean
pain score increased from 4.2 ⫾ 2.3 to 4.7 ⫾ 2.1, and
cramp score decreased from 3.6 ⫾ 2.6 to 2.3 ⫾ 2.3
after reflexology. There was no statistically significant dif-
ference between the intervention and control groups in
terms of pre-reflexology pain and cramp mean scores;
whereas, a highly significant difference was found
between the postreflexology scores of the two groups.
Pain levels of the patients in the control group increased
after reflexology, while both the pain level and cramp
severity were observed to decrease among the patients in
the intervention group (P < 0.05) (Table 5).
DISCUSSION
Fatigue is a very common problem among haemodialysis
patients, and this problem is associated with several
factors, such as the accumulation of waste products in the
body, changes in blood pressure, anaemia, staying the
same position for too long during haemodialysis treatment
and psychological reasons.13 With the help of reflexology,
© 2013 Wiley Publishing Asia Pty Ltd
270 G Özdemir et al.

Table 3 The relationship between specific characteristics of study energy flow in the body. It helps the patient in restoring
participants and their pre-reflexology score averages of fatigue, more energy by accelerating blood circulation and thus
pain and cramp enabling oxygen and nutrients to be easily transferred to
the tissues.23,28,30,31,37
Characteristics n Total fatigue Pain Cramp In the present study, the decrease in the fatigue sub-
X ⫾ SD X ⫾ SD X ⫾ SD scale and total scale scores in the intervention group and
the absence of this change in the control group indicated
Age that reflexology was effective in reducing fatigue severity.
18–32 years 12 4.4 ⫾ 1.0 4.0 ⫾ 1.2 3.4 ⫾ 1.9
In the studies conducted by Yang with breast cancer
33–47 years 18 4.9 ⫾ 2.0 3.7 ⫾ 2.1 2.7 ⫾ 2.2
patients41 and by Ko and Park with nurses, reflexology
48–62 years 36 5.7 ⫾ 1.5 4.6 ⫾ 2.4 4.0 ⫾ 2.8
ⱕ 63 years 14 6.0 ⫾ 1.2 4.7 ⫾ 2.1 3.5 ⫾ 2.3
was proved to reduce fatigue.33 Jin and Kim investigated
P = 0.024 P = 0.423 P = 0.351 the effect of reflexology on fatigue and sleep in elderly
Gender women and reported that reflexology provided quality
Female 50 5.8 ⫾ 1.4 4.8 ⫾ 3.0 4.0 ⫾ 2.6 sleep and relieved fatigue.42 Applying massage before and
Male 30 4.7 ⫾ 1.6 3.6 ⫾ 2.2 2.7 ⫾ 2.0 after reflexology to help the patients relax, applying inter-
P = 0.004 P = 0.020 P = 0.024 ventions to appropriate pressure points during reflexology
Duration of haemodialysis treatment and thus maintaining energy circulation and removing
Less than 1 year 10 5.1 ⫾ 1.5 4.5 ⫾ 2.0 4.3 ⫾ 3.2 toxins from the body may help the patients experience
1–5 years 41 5.6 ⫾ 1.7 4.4 ⫾ 2.2 3.5 ⫾ 2.3 less fatigue. Moreover, it is believed that close communi-
6–10 years 24 5.4 ⫾ 1.3 4.2 ⫾ 2.2 3.7 ⫾ 2.5 cation built with these patients during interventions made
ⱕ 11 years 5 4.3 ⫾ 1.2 4.0 ⫾ 2.2 1.8 ⫾ 1.0 them feel better, because the patients requested to con-
P = 0.240 P = 0.943 P = 0.377
tinue reflexology sessions after the completion of the
Albumin
study. When it is considered that especially patients with
Normal 22 4.6 ⫾ 1.6 3.4 ⫾ 1.9 2.8 ⫾ 2.2
Low 58 5.7 ⫾ 1.5 4.7 ⫾ 2.1 3.8 ⫾ 2.5 lower albumin levels and female patients experience
P = 0.014 P = 0.025 P = 0.133 fatigue more intensely, it may be suggested that this
URR group of patients should be given priority in reflexology
Normal 53 5.4 ⫾ 1.4 4.2 ⫾ 2.0 3.5 ⫾ 2.5 treatment.
Low 27 5.4 ⫾ 1.9 4.6 ⫾ 2.4 3.7 ⫾ 2.4 It is claimed that the stimulation of nerve points by
P = 0.767 P = 0.400 P = 0.708 certain techniques triggers electrochemical impulses,
Kt/V which in turn stimulates associated organs with the help of
Normal 69 5.4 ⫾ 1.4 4.1 ⫾ 2.1 3.5 ⫾ 2.4 neurons and provides relaxation by reducing physical
Low 11 5.4 ⫾ 2.3 5.5 ⫾ 2.1 3.6 ⫾ 2.8 tension and stress. This relaxation activates the autono-
P = 0.480 P = 0.033 P = 0.949 mous response and affects the endocrine, immune and
Haemoglobin
neuropeptide systems, respectively. The use of massage
Normal 22 5.5 ⫾ 1.5 4.7 ⫾ 2.2 3.0 ⫾ 2.6
technique during reflexology, which enables a contact
Low 58 5.3 ⫾ 1.6 4.2 ⫾ 2.1 3.77 ⫾ 2.4
P = 0.627 P = 0.415 P = 0.142
between the patient’s and practitioner’s skin, also results
Hematocrit in the release of endorphin and other chemicals. This
Normal 16 5.5 ⫾ 1.6 4.3 ⫾ 2.0 2.0 ⫾ 1.8 outcome helps in reducing pain and improving the sense
Low 64 5.3 ⫾ 1.6 4.3 ⫾ 2.2 3.9 ⫾ 2.5 of well-being.37 In this study, the decrease observed in
P = 0.568 P = 0.568 P = 0.004 postreflexology pain scores in the experimental group
unlike in the control group showed the efficacy of reflex-
ology in reducing pain severity. In different studies
which is one of the methods used in reducing this common conducted by Stephenson et al. with cancer patients,
symptom, energy flow is maintained by clearing the reflexology was reported to be effective in reducing
blocked energy channels running throughout the body and pain.27,30 Bolsoy also noted the positive effect of reflexol-
the symptom of fatigue is relieved by removing toxins ogy on relieving perimenstrual distress.37 Similarly, the
from the body.30,31,37 In addition, reflexology reduces study conducted by Degan et al. on patients with disk
stress and tension and provides relaxation by achieving hernia demonstrated the positive effect of reflexology on

© 2013 Wiley Publishing Asia Pty Ltd

The use of reflexology and hemodialysis 271

Table 4 Distribution of pre- and postreflexology fatigue subscale and fatigue score averages of patients in intervention and control groups

Behavioural/severity Affection subscale Sensory subscale Cognitive/psychological Total fatigue score

subscale subscale
X ⫾ SD X ⫾ SD X ⫾ SD X ⫾ SD X ⫾ SD

Pre-reflexology
Experimental 5.7 ⫾ 1.7 5.6 ⫾ 1.7 5.8 ⫾ 1.7 4.3 ⫾ 1.5 5.3 ⫾ 1.5
Control 5.9 ⫾ 1.9 5.9 ⫾ 1.8 5.8 ⫾ 1.7 4.5 ⫾ 1.6 5.5 ⫾ 1.6
P 0.670 0.452 0.939 0.613 0.693
Postreflexology
Experimental 3.5 ⫾ 1.4 3.3 ⫾ 1.4 3.5 ⫾ 1.7 2.9 ⫾ 1.3 3.3 ⫾ 1.4
Control 5.8 ⫾ 1.8 6.1 ⫾ 1.8 6.0 ⫾ 1.5 4.4 ⫾ 1.6 5.5 ⫾ 1.5
P 0.000 0.000 0.000 0.000 0.000

Table 5 The relationship between pre- and postreflexology pain include plasma volume contraction (application of exces-
and cramp severity score averages in intervention and control sive ultrafiltration for removing the excess fluid received
groups in the interdialytic period), hypotension, hyponatremia,
hypomagnesemia and the impairment of muscle energy
Pain Cramp metabolism induced by carnitin deficiency.3,4,10,20,22,45
X ⫾ SD X ⫾ SD The decrease in cramp scores in the experimental group
after reflexology and the absence of such a change in
Pre-reflexology the control group indicated the effect of reflexology
Experimental 4.4 ⫾ 1.1 3.4 ⫾ 2.3
in reducing cramp severity. Similarly, Ho et al. also
Control 4.2 ⫾ 2.3 3.6 ⫾ 2.6
reported the efficacy of reflexology in reducing cramp
P 0.722 0.723
Postreflexology
severity.32 The application of reflexology in the control
Experimental 1.6 ⫾ 1.7 1.1 ⫾ 1.8 of this symptom, which is experienced very frequently in
Control 4.7 ⫾ 2.1 2.3 ⫾ 2.3 haemodialysis treatment and which causes significant dis-
P 0.000 0.001 comfort in patients, may also prevent the early termina-
tion of treatment by facilitating patients’ compliance to
treatment, because patients experience this symptom
pain.43 At the end of Lacey’s study on the effect of reflex-
very frequently and severely during some haemodialysis
ology on anxiety, pain and nausea in cancer patients, a
sessions and sometimes request the early termination of
decrease was observed in the severity of these symp-
the treatment.
toms.44 In brief, the positive effect of reflexology on the
symptom of pain was demonstrated in several studies, and
parallel results were obtained in the present study. Con- CONCLUSION
sidering that reflexology is a non-invasive, convenient and Consequently, based on the assessment of the findings
relaxing technique, it may be used safely in the control of obtained from this experimental study, it was determined
pain that affects patients’ quality of life and compliance to that reflexology reduced the fatigue subscale scores and
dialysis program in a negative way. Since it was detected total scale scores as well as pain and cramp mean scores in
that especially women and patients with low albumin and the intervention group. Thus, reflexology may be recom-
Kt/V levels experience pain more intensely, reflexology mended for controlling fatigue and pain symptoms and
application may be recommended for this group of reducing cramp severity especially in patients with lower
patients to evaluate pain severity on a more frequent basis albumin level as well as in the elderly and women
and to reduce pain severity. patients.
Several factors are thought to be responsible from the All in all, it may be suggested that reflexology, which is
pathogenesis of cramps in dialysis patients. These factors a complementary method used for establishing a closer

© 2013 Wiley Publishing Asia Pty Ltd

272
contact with patients and for improving patients’ quality
of life by reducing the severity of fatigue, pain and cramp,
should be applied by trained professionals in combination
with pharmacological methods, and further studies should
be conducted with larger populations and research results
should be reflected on patient care.
Limitations of this study
This study has several limitations. One limitation is the
small size of the sample, which makes findings difficult to
be generalizable to all Turkish haemodialysis patients. The
second limitation is the fact that the effect of reflexology
was assessed only symptoms of pain, cramps and fatigue,
excluding other potential symptoms that haemodialysis
patients may experience. Consequently, it might be more
reasonable to evaluate the effect of reflexology on other
symptoms and to make a comparison of reflexology to
other methods in future studies.
ACKNOWLEDGEMENT
We would like to thank all the patients who accepted to
participate in the study.
REFERENCES
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3rd edn. Samsun, Turkey: Ceylan Ofset, 2010.
2 Harris D, Elder G, Kairaitis L, Rangan G (eds). Basic Clinical
Dialysis. Translated by Kazancı G, İstanbul, Turkey: Nobel
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