European Journal of Integrative Medicine 45 (2021) 101344

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European Journal of Integrative Medicine

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

Clinical Trial

The effect of foot reflexology on pain, comfort and beta endorphin levels in
patients with liver transplantation: A randomized control trial
Gürkan Kapıkıran a,∗, Meral Özkan b
a
Faculty of Health Sciences, Bingol University, Bingol, Turkey
b
Surgical Nursing Department, Nursing Faculty, Inonu University, Malatya, Turkey

a r t i c l e i n f o a b s t r a c t

Keywords: Introduction: Research suggests that reflexology stimulates the release of endorphins and is effective for the
Liver transplantation control of pain. The aim of study was to determine the effect of foot reflexology on the levels of pain, comfort
Reflexology and beta endorphins in patients who had undergone liver transplantation.
Pain
Comfort Methods: This randomized controlled study was conducted between October 2019–April 2020 on adult patients
Beta endorphin who received a liver transplantation at a Liver Transplant Institute in Turkey.
Randomized controlled trial
The sample consisted of 120 patients randomized to receive either reflexology or routine care. Data collected
included; Patient Information, a Numerical Pain Scale, Perianesthesia Comfort Scale and Beta Endorphin Level
Registration Form. Prior to receiving foot reflexology, pain, comfort and beta endorphin levels of patients were
determined. Reflexology was applied by the researcher for 30 minutes. Pain, comfort and beta endorphin levels
were determined immediately after foot reflexology. The patients in the control group were tested at the same
time intervals without any application other than the routine clinical protocol.
Results: After applying foot reflexology, the intervention group showed a statistically significant decrease in pain
level compared to the control group (Cohen’s d = 1.95, 95% confidence interval (CI): −-2.7261 to −1.8738; p <
0.001). Both beta endorphin and comfort levels for both intervention and control groups increased statistically
post test compared to the initial test (p < 0.05). However, although the increase in beta endorphin and comfort
levels was observed to be higher in the intervention group this was not significantly different to the controls.
Conclusion: Pain levels of the patients who received foot reflexology decreased more than for those patients who
did not receive reflexology, and their beta endorphin and comfort levels increased more. Reflexology could be
used as a non pharmacological treatment option offered in post-operative nursing care.

1. Introduction
Liver transplantation is the transfer of the liver which is taken from a
living donor who has compatible blood and tissue with the patient or a
brain-dead cadaver donor [1]. Today, the survival rate after transplan-
tation has increased in line with the developments in transplantation
technologies and immunosuppressive therapy. Thus, surgical interven-
tions have ceased to be the last resort method and become a common
treatment for end-stage liver patients [1,2]. According to the Global Ob-
servatory on Donation and Transplantation data, 90161 liver transplan-
tations were performed in the world between 2017 and 2019, and of
them, 4809 were performed in Turkey. This situation increased the im-
portance attributed to healthcare management after transplantation [3].
Providing care for the living donor and recipient in the best conditions
in transplantation procedures is as important as the transplantation of
∗
Corresponding author.
E-mail address: gurkankpkrn@gmail.com (G. Kapıkıran).
the organ [4]. In this regard, nurses take great responsibility after trans-
plantations operations which are quite complex and risky interventions.
Today, pharmacological methods are commonly used for post-op pain
control due to their rapid effect and easy application [5]. However, ef-
fective pain control cannot always be maintained with analgesics [6].
Therefore, the use of nonpharmacological methods has also increased
due to their pain-relieving effects in addition to pharmacological meth-
ods [5]. Reflexology, which is among nonpharmacological methods, is a
popular and non-invasive method that dates back to five thousand years
and is used in pain treatment by activating the body’s own natural heal-
ing and energy regions [7]. Reflexology is a massage technique applied
to certain points in the hands, feet and ears that stimulate the reflex
points corresponding to certain parts of our body [7–9]. For reflexology
application, the fact that the reflex points where the organs reflect, are
in a wider area on the feet makes the feet more preferable [7]. Thanks
to the pressure and massage applied to these reflex points, energy block-
ages are broken and it provides relief by helping the normalization of
body functions by creating reflex effects on organs, muscles and nerves

https://doi.org/10.1016/j.eujim.2021.101344
Received 23 December 2020; Received in revised form 6 May 2021; Accepted 7 May 2021
1876-3820/© 2021 Elsevier GmbH. All rights reserved.
G. Kapıkıran and M. Özkan
corresponding to body cells [8,9]. Therefore, reflexology is effective
in controlling pain by stimulating the release of various chemical sub-
stances and endorphins, thanks to the pressure and massage applications
applied to the reflex points [10]. There are various studies that exam-
ine the effect of reflexology on pain in the literature. Sadeghi Shermeh
et al. found that foot reflexology performed after coronary artery bypass
graft surgery is useful for reducing pain [11]. Khorsand et al. found that
foot reflexology performed on patients after appendectomy operation
are effective on reducing pain [12]. According to the results of studies
that examined the effect of reflexology on pain control,and reflexology
is regarded a complementary method [10–14]. Although there are vari-
ous studies that examined the effect of foot reflexology on pain, none of
them were conducted with patients who received liver transplantation.
While there are no studies that examined the effect of foot reflexology
on the comfort levels of patients with liver transplantation, there are
limited number of studies [15] that examined the effect of back mas-
sage on the patients’ comfort levels. Even though it was reported that
reflexology increases the beta-endorphin (𝛽-Endorphin) level, the num-
ber of studies that investigated the level of endorphin after reflexology
is limited [16]. Therefore, this study was conducted to determine the
effect of foot reflexology on pain, comfort and 𝛽- Endorphin levels of
patients who received liver transplantation.
2. Materials and methods
2.1. Design and sample
This was a randomized controlled trial at an organ transplantation
clinic of the Liver Transplantation Institute (LTI) in Turkey between De-
cember 2018 and July 2020. Approximately 225 liver transplantations
are performed in the LTI in a year. The population of the study included
147 patients who received liver transplantations in the LTI. The sample
size was determined with the G Power 3.1.9.7 program. According to
the performed power analysis measurement with 0.7 effect size, 0.05
margin of error, 0.95 confidence interval and 95% power to represent
the universe, it was determined that 120 patients (60 in the interven-
tion group, 60 in the control group) should be included in the study.
The research protocol was designed according to the CONSORT (Con-
solidated Standards of Reporting Trials Statement) guidelines [17]. The
sample included the patients who met the inclusion criteria and who
were selected from the population with the improbable random sam-
pling method. 16 patients who did not meet the inclusion criteria and
11 patients who did not agree to participate in the study were excluded
from the study (Fig. 1).
Numbers from 1 to 120 were randomly divided into two blocks ac-
cording to the algorithm created by the computer program [18]. The
blocks for the intervention and control groups were determined by lot-
tery method. The first block was determined to be the control group
while the second block was determined to be the intervention group.
2.2. Inclusion and exclusion criteria for participants
Inclusion criteria were being: (i) Patients undergoing liver transplan-
tation, (ii) 18 years of age or older, (iii) ability to communicate verbally
and not having a cognitive problem, (iv) a definition of pain severity of
4 and above, and (v) willing to participate in the study. The exclusion
criteria were having: (i) the absence of open wounds and cellulite in
the area to be applied, (ii) the absence of thrombophlebitis, deep vein
thrombosis, inflammatory diseases, etc., and (iii) psychiatric illness.
2.3. Data collection tools
Patient Identity Form: This form was prepared by the researcher in
which the sociodemographic and medical characteristics of the patients
are recorded.
2
European Journal of Integrative Medicine 45 (2021) 101344
Numeric Pain Scale: It is a numeric scale which is based on explain-
ing pain severity with numbers, and where 0 point means no pain and
10 points mean unbearable pain. Numerical scales have been adopted
more because they facilitate the definition of pain severity, scoring and
recording [19,20]. Thus, NPS was used in this study.
Beta-Endorphin Level Entry Form: This form, in which the 𝛽- Endor-
phin level determined after laboratory analysis is recorded, was estab-
lished by the researcher.
Perianesthesia Comfort Questionnaire: PCQ was established based
on the taxonomic structure which forms the hypothetical compo-
nents of the comfort hypothesis. It has 24 items in a six-point
Likert-type scale. Half of the items in PCQ have negative content
(2,3,4,7,8,9,10,12,13,15,17,22) and the other half of them have posi-
tive content (1,5,6,11,14,16,18,19,20,21,23,24). To calculate the total
score from the PCQ, the scoring of negative statements is reversed and
added up with the positive items of the scale. The mean value is de-
termined after the total score obtained from the PCQ is divided to the
number of items, and the result is determined within the distribution of
1-6 in six-point Likert-type. While low total score on PCQ indicates poor
comfort, high total score on PCQ indicates good comfort [21,22]. In the
Turkish validity and reliability studies of the PCQ that were conducted
by Üstündağ and Aslan, the Cronbach’s alpha coefficient was 0.83 [23].
The Cronbach’s alpha coefficient was 0.89 in this study.
2.4. Data collection
Data were collected by the first researcher with the face-to-face inter-
view method between October 2019 and April 2020. Since the patients
in the intervention and control groups stayed in intensive care unit for
two days after the operation, the data were collected every weekday and
on Sundays from the third postoperative day. During the study period,
no adverse events were noted in both study groups (intervention and
control) and in the laboratory analysis phase.
2.4.1. Intervention group
The first researcher received hands-on training about reflexology ap-
plication before the study started. The researcher applied foot reflexol-
ogy on the patients with liver transplantation in the intervention group
in one session (30 minutes) after the operation. Patient confidential-
ity was maintained in all procedures. It was ensured that the environ-
ment was as quiet and calm as possible for the concentration of the re-
searcher and the patient during the application. Television and monitor
sounds were reduced and phone tones were muted and turned to silent
mode. The patient was asked to lie down in supine position and the re-
searcher prepared the patient for reflexology by supporting their feet
with a pillow. After completing all preparations and washing her/his
hands, the researcher took some petroleum jelly and rubbed her/his
hands and brought it to body temperature. The pre-test is the period
before the application of this reflexology intervention, the post-test im-
mediately after the 30-minutes reflexology session. The patient identity
form was implemented before reflexology application. Pain and com-
fort levels were assessed as the pre-test. Then, venous blood was taken
to determine the plasma 𝛽- Endorphin level. Foot reflexology was first
applied on the right foot, which is effective on the sympathetic ner-
vous system, for 15 min and then, on the left foot, which is effective on
the parasympathetic nervous system, for 15 min. Foot warm-up move-
ments, which are the first step of foot reflexology, were applied on the
right foot for 2 min. Then, the warm-up movements were ended by ap-
plying deep and painless pressure on the solar plexus area of the foot, on
which reflexology was applied, for 1 min. Then, reflexology was applied
on brain (epiphysis area on the thumb, hypothalamus, pituitary points),
liver, thyroid, small and large bowels, knee, hip, elbow and shoulder
areas and lymphatic system areas (Fig. 2). Relaxation movements were
then performed, and the session on the right foot session was completed
within 15 minutes with the application of pressure on the solar plexus.
G. Kapıkıran and M. Özkan
Same process was performed on the left foot and the reflexology appli-
cation was completed within 15 min. Venous blood was taken again to
assess the 𝛽- Endorphin level as the post-test after the application, and
the NPS and PCQ were implemented again.
2.4.2. Control (no treatment) group
The patient identity form, NPS and PCQ were applied on the patients
in the control group as the pre-test. After the questions were answered,
venous blood was taken to determine the plasma 𝛽- Endorphin level.
No intervention other than clinical protocol was applied on the control
group, and after taking venous blood after 30 minutes to determine 𝛽-
Endorphin level, the NPS and PCQ were re-applied as the post-test.
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European Journal of Integrative Medicine 45 (2021) 101344
Fig. 1. Research Flow Chart.
2.5. Laboratory analyses
Venous blood was taken from the patients on the 0 and 30 min-
utes to measure the 𝛽- Endorphin level. 5 mL venous blood sample
taken from each patient with a sterile single-use 10 cc injector was
poured into gold BD Hemogard capped tubes. Blood samples were kept
upright at room temperature for 15-20 minutes, then they were cen-
trifuged at +4 ° C, 2000-3000 gauge for 20 minutes. Following the cen-
trifugation, the separated serum was taken from the tubes and stored
in Eppendorf tubes at -80 ° C. After completing taking blood sam-
ples, serums were thawed and studied in accordance with the kit pack-
age insert (Catalog No: YL191012375, YL191012376, YL191012377)
to determine 𝛽- Endorphin level. The laboratory analyses were per-
G. Kapıkıran and M. Özkan
Fig. 2. Reflexology application.
formed by experts in the Microbiology Department Laboratory of a
university.
2.6. Data analysis
The data were analyzed using the Statistical Package for the Social
Sciences (SPSS) 24.0 analysis program and the statistical significance
level was p < 0.05. Kolmogorov-Smirnov test was used to determine
whether the data distribution was normal. Percentage, mean and stan-
dard deviation tests were used in the analysis of demographic data. In-
dependent sample t-test, paired t-test and chi-square test were used to
compare nominal data. A Cohen’s d calculation was used between the
group difference measures to determine the effect sizes. Cohen explained
that the effect size of a small effect was 0.2, a medium effect was 0.5,
and a large effect size was 0.8. [24].
2.7. Ethical considerations
This study was approved by the Malatya Clinical Studies Ethics Com-
mittee (Date: 26/12/2018, Decision No: 2018/183). Clinical trial reg-
istration and number: NCT04828356. All participants voluntarily par-
ticipated in the study. The purpose of the study was explained by the
researchers, and informed signed consent was obtained from those who
agreed to participate in the study. To those who voluntarily participated
in the research; the researchers have committed that all their informa-
tion will be kept confidential, that the data obtained will only be used
for research purposes, and that they can withdraw from the research at
any time. The research was carried out in accordance with the Helsinki
Declaration principles.
3. Results
3.1. Characteristics of the participants
The results of the study, which was conducted to determine the ef-
fect of foot reflexology on pain, comfort and 𝛽- Endorphin levels of
patients who received liver transplantation, are presented in this sec-
tion. Table 1 shows the distribution of the participants, who received
liver transplantation, based on their sociodemographic characteristics.
4
European Journal of Integrative Medicine 45 (2021) 101344
The mean age of the patients in the intervention group was 47.96 ±
11.36 and the mean age of the patients in the control group was 51.26
± 13.90. The patients in the intervention group showed an even distri-
bution in terms of sex, and of these, 75% were married, 33.3% were uni-
versity graduates, 28.3% were office workers and 48.3% had an income
equal to their outgoings. Of the patients in the control group, 53.3%
were female, 86.7% were married, 25% were high school graduates,
21.7% were retired and 53.3% had an income lower than their outgoings
(Table 1).
3.2. Medical characteristics of the participants
Table 1 shows the distribution of the patients in terms of medical
characteristics. Of the patients in the intervention group, 25% were di-
agnosed 3-5 months before, 41.7% were hospitalized for 1-7 days, 83.3%
received a transplantation from a living donor, 21.7% had Hepatitis C
as their transplantation etiology, and 76.7% had a chronic condition.
Of the patients in the control groups, 31.7% were diagnosed within 12
months or more, 30% were hospitalized for 8-14 days, 85.0% received a
transplantation from a living donor, 18.3% had Hepatitis B and Hepatitis
C as their transplantation etiology, and 73.3% had a chronic condition
(Table 1).
3.3. Pain, comfort and beta endorphin score averages of the participants
Table 2 shows the comparison of the pain, comfort and beta endor-
phin levels of the intervention and control groups at the 0th (pre-test)
and 30th (post-test) minutes. According to this; there was a statistically
significant difference between the pre-test pain levels (Cohen d = 0.58,
95% confidence interval (CI): 0.1364 to 0.5968) of the patients in the
intervention and control groups (p < 0.05). There was a statistically sig-
nificant difference between the post-test pain levels (Cohen’s d = 1.95,
% 95 CI: −2.7261 to −1.8738) of the patients in the intervention and
control groups (p < 0.05). There was a statistically significant differ-
ence between the pre-test comfort levels (Cohen’s d = 0.83, % 95 CI:
−15.7056 to −6.0610) of the patients in the intervention and control
groups (p < 0.05). There was a statistically significant difference be-
tween the post-test comfort levels (Cohen’s d = 0.76, % 95 CI: 4.6033
to 12.7966) of the patients in the intervention and control groups (p <
G. Kapıkıran and M. Özkan European Journal of Integrative Medicine 45 (2021) 101344

Table 1
Socio-demographic and medical characteristics of patients.

Characteristics Experimental group(n = 60) Control group(n = 60) Statistical significance

Age (𝑥̄ +SS) (𝑥̄ +SS) t: −1.423

47.96 ± 11.36 51.26 ± 13.90 p: 0.157
(30–71) (23–78)
Min-Max Min-Max

N % N % 𝝌 2 /p

Gender
Female 30 50.0 32 53.3 𝜒 2 : 0.133
Male 30 50.0 28 46.7 p: 0.715
Marital status
Married 45 75.0 52 86.7 𝜒 2 : 2.636
Single 15 25.0 8 13.3 p: 0.104
Educational level
Illiterate 3 5.0 11 18.3 𝜒 2 : 6.663
Literate 10 16.7 11 18.3 p: 0.155
Elementary 12 20.0 11 18.3
High School 15 25.0 15 25.0
University 20 33.3 12 18.7
Employment status
Civil Servant 17 28.3 9 15.0 𝜒 2 : 7.592
Worker 7 11.7 8 13.3 p: 0.180
Self-employment 9 15.0 8 13.3
Housewife 11 18.3 9 15.0
Retired 4 6.7 13 21.7
Unemployed 12 20.0 13 21.7
Economic situation
Income less than expense 28 46.7 32 53.3 𝜒 2 : 0.630
Income-expense equal 29 48.3 26 43.3 p: 0.730
Income more than expense 3 5.0 2 3.3
Time since diagnosis
0–2 months 12 20.0 9 15.0 𝜒 2 : 3.445
3–5 months 15 25.0 9 15.0 p: 0.486
6–8 months 10 16.7 13 21.7
9–11 months 10 16.7 10 16.7
12 months and over 13 21.7 19 31.7
Duration of hospitalization
1–7 day 25 41.7 15 25.0 𝜒 2 : 9.321
8–14 day 22 36.7 18 30.0 p: 0.054
15–21 day 7 11.7 9 15.0
22–28 day 4 6.7 10 16.7
29 day and over 2 3.3 8 13.3
Donor type
Living 50 83.3 51 85.0 𝜒 2 : 0.063
Cadaveric 10 16.7 9 15.0 p: 0.803
Liver transplant etiology
Hepatitis C 13 21.7 11 18.3 𝜒 2 : 3.932
Idiopathic liver failure 10 16.7 10 16.7 p: 0.864
Cryptogenic liver disease 10 16.7 8 13.3
Hepatitis B 9 15.0 11 18.3
Autoimmune hepatitis 6 10.0 6 10.0
Budd-Chiari Syndrome 4 6.7 1 1.7
Wilson’s Disease 4 6.7 6 10.0
Hepatocellular Carcinoma (HCC) 3 5.0 4 6.7
Ethanol Cirrhosis 1 1.7 3 5.0
Chronic disease status
Yes 46 76.7 44 73.3 𝜒 2 : 0.178
No 14 23.3 16 26.7 p: 0.673

0.05) (Table 2). No significant differences were found between the pre-
test 𝛽- Endorphin levels (Cohen’s d = 0.25, % 95 CI: −0.2832 to 0.5947)
of the patients in the intervention and control groups (p > 0.05). There
was a statistically significant difference between the post-test 𝛽- Endor-
phin levels (Cohen’s d = 0.59, % 95 CI: 0.1956 to 0.7796) of the patients
in the intervention and control groups (p < 0.05).
According to intergroup comparisons on Table 2, there was a statis-
tically significant difference between mean pain levels of the patients in
the intervention group before (4.72 ± 0.72) and after (2.02 ± 1.36) the
reflexology (p < 0.05). No significant difference was found between the
levels of pain measured on the 0 (4.35 ± 0.54) and 30 minutes (4.32
± 0.96) of the patients in the control group (p > 0.05). There was a
statistically significant difference between the mean scores of the 𝛽- En-
dorphin level of the patients in the intervention group before (0.52 ±
0.48) and after (1.31 ± 0.97) reflexology (p < 0.05). The 𝛽- Endorphin
level of the patients in the control group on 0 minute was 0.64 ± 0.46
and it was 0.83 ± 0.60 on the 30 minutes. Although it increased rel-
atively less than the intervention group, the difference between the 𝛽-
Endorphin levels on the 0 and 30 minutes was statistically significant
(p < 0.05). The comfort level of the patients in the intervention group
before reflexology was 102.25 ± 12.19 and it was 133.13 ± 6.74 after
reflexology. This difference between the mean scores of comfort level
before and after reflexology was statistically significant (p < 0.05). The
comfort level of the patients in the control group on the 0 minute was
113.33 ± 14.40 and it was 124.43 ± 14.53 on the 30 minutes. Although
it increased relatively less than the intervention group, this difference

5
G. Kapıkıran and M. Özkan European Journal of Integrative Medicine 45 (2021) 101344

Table 2
Comparison of pain, comfort and beta endorphin score averages of patients.

Experimental group Control group Intergroup Comparison

Measurement Time
𝑥̄ +SS 𝑥̄ +SS Pb %95 CI d

Pain Level 0 minutes 4.72±0.72 4.35±0.54 p: 0.002∗ 0.1364 to 0.5968 0.58

30 minutes 2.02±1.36 4.32±0.96 p: 0.000∗ -2.7261 to -1.8738 1.95
Intragroup Comparison pa p: 0.000∗ p: 0.823
Comfort Level 0 minutes 102.25±12.19 113.33±14.40 p: 0.000∗ -15.7056 to -6.0610 0.83
30 minutes 133.13±6.74 124.43±14.53 p: 0.000∗ 4.6033 to 12.7966 0.76
Intragroup Comparison pa p: 0.000∗ p: 0.000∗
Beta Endorphin Level 0 minutes 0.52±0.48 0.64±0.46 p: 0.199 -0.2832 to 0.5947 0.25
30 minutes 1.31±0.97 0.83±0.60 p: 0.001∗ 0.1956 to 0.7796 0.59
Intragroup Comparison pa p: 0.000∗ p: 0.001

pa → paired samples T test.

b
→ independent samples T test.
CI→Confidence interval, d→ Cohen’s d.
∗
p < 0.05.

Table 3
Analgesic Applications for Post-Operative Pain Management.

Experimental Control Statistical

Analgesic Applications group(n=60) group(n=60) Significance

S % S % 𝝌 2 /p

Analgesic use status ∗

Yes 39 65.0 30 50.0 𝜒 2 : 2.762
No 21 35.0 30 50.0 p: 0.097
Analgesic type used
Non-Steroid Anti-Inflammatory 32 82.1 25 83.3 𝜒 2 : 0.019
Opioids 7 17.9 5 16.7 p: 0.889
Analgesic usage hours
Before reflexology 21 46.2 13 43.3 𝜒 2 : 0.750
During reflexology 18 53.8 17 56.7 p: 0.387

𝜒 2 → Chi square ∗ Analgesic use in the last 24 hours.

between the pre- and post-test comfort levels was statistically significant
(p < 0.05) (Table 2).
3.4. Analgesic applications for post-operative pain management
Analgesics protocols performed after the operation for pain manage-
ment are presented in Table 3. No significant difference was found be-
tween the intervention and control groups in terms of using analgesics,
type of analgesics used, and time of using analgesics (p > 0.05). Of the
patients in the intervention group, 65% used analgesics, and 82.1% of
those, who used analgesics, used a non-steroidal anti-inflammatory and
53.8% were given analgesics during reflexology. Of the patients in the
control group, 50% used analgesics, and 83.3% of those, who used anal-
gesics, used a non-steroid anti-inflammatory and 56.7% were given anal-
gesics during reflexology (Table 3).
4. Discussion
This study examined the effect of foot reflexology on the pain, com-
fort and 𝛽- Endorphin levels of the patients who received liver trans-
plantation. There were no significant differences between the patients
in the intervention and control groups in terms of sociodemographic
characteristics (p > 0.05). According to obtained results, both groups
were similar in terms of sociodemographic characteristics and medical
characteristics (Table 1).
This study found that the pain levels of the patients who received
foot reflexology significantly decreased after reflexology (p < 0.05)
(Table 2). There are no studies that have examined the effect of foot re-
flexology on pain level after liver transplantation in the literature. How-
ever, there are studies which showed that reflexology application on dif-
ferent patient groups decreased the pain level [10–14,25,26]. Khorsand
et al. examined the effects of foot reflexology on analgesic consumption
and pain control after appendectomy and found that pain severity de-
creased in the intervention group [12]. In the studies by Babajani et al.
and Shermeh et al. conducted with coronary artery bypass graft (CABG)
patients, it was revealed that foot reflexology significantly decreased
pain [11,26]. Park et al. found that foot reflexology applied after mas-
tectomy decreased pain scores [27]. In another relevant study by Tsay
et al., it was found that foot reflexology decreased the pain levels of
patients who had digestive system cancer and underwent surgery [28].
Ozturk et al. determined that foot reflexology applied on the patients
after abdominal hysterectomy surgery decreased the pain level [26].
Numerous studies conducted with different surgical patient groups de-
termined that hand and foot massages decreased the pain level [29–34].
The analgesic effect induced by reflexology and massage develops due
to the fact that mechanical stimulations on the skin, subcutaneous tis-
sue and muscles prevents pain impulses, increases endorphin secretion
and activates high-level inhibitory mechanisms [35,36]. The pressure
and massage applied to the reflex points through reflexology applica-
tion enable breaking the energy blockages and spreading this energy
flow toward respective organs in a balanced fashion [7]. It has also been
reported that the release of endorphins along with the release of many
chemicals have an effect on pain control [10]. The results of this study
showed that foot reflexology applied after liver transplantation in addi-
tion to pharmacological methods decreased the pain. This study result
is similar to the results of other relevant studies in the literature.
This study found that the comfort levels of the patients who received
foot reflexology significantly increased compared with controls (p <
0.05) (Table 2). There were no studies that have evaluated the effect of
foot reflexology applied on patients who received liver transplantation
on the level of comfort in the literature. However, only one study in the
literature found that back massage increased the comfort levels of the
patients with liver transplantation [15]. In this regard, the study data on
the comfort level were compared with the studies conducted with other

6
G. Kapıkıran and M. Özkan
manipulative and body-based treatment methods except for foot reflex-
ology. In a relevant study conducted with various patient groups ex-
cept for liver transplantation, it was found that massage applications on
hand, foot, arm and leg increased the comfort level [37–39]. Thus, Kol-
caba reported in his theory that relaxing interventions (massage, music
therapy, dreaming, etc.) are effective on increasing the comfort [40,41].
The results of the study show that foot reflexology is effective on increas-
ing the comfort levels of the patients who received liver transplantation
(Table 2). This study result is similar to the results of the relevant studies
in the literature.
The study found that the 𝛽- Endorphin levels of the patients who
received foot reflexology significantly increased (p<0.05) (Table 2). Al-
though the increase in the 𝛽- Endorphin levels of the patients in the con-
trol group was relatively less than the intervention group, this increase
was statistically significant (p<0.05). This increase in the 𝛽- Endorphin
levels of the patients in the control group, on whom no intervention was
applied, is thought to be induced by the analgesic treatment applied ac-
cording to clinical protocols (Table 2). There was only one study that
measured the effect of foot reflexology application on the 𝛽- Endorphin
level in the literature [16]. McCullough et al. found that the foot reflex-
ology that they applied on pregnant women for 6 weeks had no signif-
icant effect on the 𝛽- Endorphin level [16]. Various studies conducted
with different patient groups determined that back massage and con-
nective tissue massage also increased the 𝛽- Endorphin level [42–45].
According to endorphin theory, skin stimulations such as TENS, reflexol-
ogy, massage and touching and applications such as music therapy and
humor, etc. increase the release of 𝛽- Endorphin, one of the endogenous
neurotransmitters, which are the natural pain relievers produced by the
body, and play an active role in the analgesia system, and helps to the
pain control [20,46,47]. The results of the study show that foot reflex-
ology is effective on increasing the 𝛽- Endorphin levels of the patients
who received liver transplantation (Table 2). The study results are simi-
lar to the results of the relevant studies in the literature. This study is the
first randomized controlled trial to suggest that foot reflexology reduces
pain more effectively than routine care, and may increase 𝛽- Endorphin
and comfort levels in patients undergoing liver transplantation. Other
problems, especially pain after liver transplantation, negatively affect
patient comfort. Nurses can reduce pain and increase patient comfort
with non-pharmacological methods which could be applied in addition
to pharmacological methods during postoperative recovery which is a
very sensitive period. Foot reflexology, one of these nonpharmacologi-
cal methods, is non-invasive, easily applied, safe and can be provided at
low cost.
4.1. Limitations
This study has some limitations. First, the patient group in this study
was limited to patients hospitalized for liver transplantation in an organ
transplant clinic in one center. The results obtained from this study con-
ducted in a single center cannot be generalized to all liver transplant pa-
tients. However, it can be used to compare with other study results.The
second is that the application of foot reflexology was conducted in only
one session of 30 mins but this may also be an advantage.
5. Conclusion
The results of this study revealed that foot reflexology decreased the
pain level and increased the 𝛽- Endorphin and comfort levels.
In accordance with these results, it can be recommended that given
the increasing number of nurses who provide care to patients after liver
transplantation operations, should have knowledge of foot reflexology.
In the period when postoperative recovery is very sensitive, nurses ap-
plying non pharmacological methods such as foot reflexology in addition
to pharmacological treatment methods can help in reducing pain and in-
crease the comfort of patients. More studies that examine the effects of
foot reflexology on other patient groups and evaluate the effectiveness
7
European Journal of Integrative Medicine 45 (2021) 101344
of foot reflexology applications repeated in the late postoperative period
should also be conducted.
Author contribution
The main idea of the study was determined by GK and MO. The pilot
study was done by GK. Conceptualization: GK and MO. Methodology:
GK and MO. Formal analysis: GK. Investigation: MO. Data collection:
GK. Data improvement: GK. Writing - Original draft preparation: GK.
Writing-Review and Editing: MO and GK. Visualization: GK. Supervi-
sion: MO. Project administration: MO. We confirm that the manuscript
has been read by all the mentioned authors and that there are no other
people who meet the authorship criteria but are not listed.
Financial Support
This study was supported by İnönü University Scientific Research
Projects Coordination Unit as the project numbered 1751.
Declaration of Competing Interest
The authors declare no conflict of interest.
Acknowledgments
The researchers are grateful to İnonu University Scientific Research
Projects Coordination Unit for their financial support and the staff of the
Department of Microbiology for their help at the laboratory stage. Ad-
ditionally, the researchers would like to thank all liver transplantation
patients who received liver transplantation in İnönü University Turgut
Özal Medical Center LTI and participated in this study for their cooper-
ation.
Data availability
Data and additional materials regarding this article can be obtained
from the respective authors on request.
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