INTERVENSI MANDIRI 1

“Research on the Effect of the Foot Bath and Foot Massage on Residual Schizophrenia
Patient”

Disusun Untuk Memenuhi Tugas Stase Keperawatan Jiwa

Dosen Pengampu : Endang Nurul Syafitri, S.Kep., Ns., MSN

Disusun Oleh :
Kelompok 1 (Kelas 06)
1. Adrianie Moenaningsih (20160124)
2. Christine Phatalo (20160122)
3. Desak Putu Ari Safitri (20160054)
4. Gusti Ayu Saraswati (20160106)
5. Hokpitasari Sumartiani (20160062)
6. Jeni Andrelyanis (20160001)
7. Jumratul Islam (20160111)
8. Kevin Richard Pratama (20160070)

PROGRAM STUDI PENDIDIKAN PROFESI NERS

FAKULTAS ILMU KESEHATAN
UNIVERSITAS RESPATI YOGYAKARTA
2021
 LAMPIRAN JURNAL (ASLI)

Research on the Effect of the Foot Bath and Foot Massage on Residual
Schizophrenia Patients

Kazuko Kito, Keiko Suzuki

PII: S0883-9417(16)00003-0

DOI: doi: 10.1016/j.apnu.2016.01.002

Reference: YAPNU 50806

To appear in: Archives of Psychiatric Nursing

Please cite thisonarticle

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Schizophrenia K., Research
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 Research on the Effect of the Foot Bath and Foot Massage on Residual
Schizophrenia Patients

KITO Kazuko ACCEPTED

SUZUKI Keiko

MANUSCRIPT

1
Abstract
Researchers performed foot baths and massages for residual schizophrenia patients to

ACCEPTED
gauge the effects on psychiatric symptoms. Subjects were six residual schizophrenia
patients hospitalized in a psychiatric hospital. Three times a week for 4 weeks, they
received an 8-minute effleurage massage to their legs after a 10-minute foot bath. The

MANUSCRIPT
effect of physiological relaxation was identified by a significant decline in heart rate in
all cases. The results of the Positive and Negative Symptom Scale are as follows: a
mean score of 29.0 was measured before treatment, which lowered to 21.5 after
treatment, indicating that foot care improved their negative symptoms (p<0.05).The
results of the Quality of Life Scale before the foot care intervention, was 10.5 and
increased to 34.0 after the intervention, indicating improvement in their quality of life
(p<0.05). The results of the two measurements indicate that foot baths and massages
were effective in improving psychiatric symptoms.
Keywords: foot bath, foot massage, residual schizophrenia
INTRODUCTION
Psychiatric care in Japan has been shifting from hospital-oriented care to community-

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oriented care. As a result, hospitalization days in psychiatric hospitals have been
gradually reduced. No significant change has been observed for the discharge of
inpatients staying in a hospital longer than a year, however, and the issues related to

MANUSCRIPT
long-term hospitalization have not been resolved yet. (The Ministry of Health, Labor
and Welfare, 2014) According to a survey conducted by the Ministry of Health, Labor
and Welfare in 2010, in recuperation wards at psychiatric hospitals, inpatients with
scores below 40 on the Global Assessment of Functioning (GAF) account for 64% of
all inpatients. Many of those hospitalized in recuperation wards are residual
schizophrenia patients, who are easily affected by delusions or auditory hallucinations,
making them gravely communication-impaired.
In psychiatric wards, various types of rehabilitation have been undertaken in order to
relieve stress in social life and prevent recurrence (Iwasaki, 2010). However, there are
some schizophrenia patients who are not willing to undertake any rehabilitation
therapy no matter how hard nurses urge them to.
In the field of psychiatry, it was once said that physical care was intrusive and in
some cases could be a security threat for schizophrenia patients because their ego
boundaries were unclear (Kayama, 1999). However, according to Nakai (1984), once
patients had distinct psychological boundaries, physical care gave them a sense of
security and even relieved their anxiety. In addition, the importance of nursing through
physical care started drawing attention in the field of psychiatric nursing care. In fact,
it was suggested that physical care provided patients with comfort as well as relief,
helping to establish a relationship of mutual trust between patients and their
caregivers (Urayama et al., 2008) while also helping vulnerable patients recover their
ego functionality (Terasawa, 2004). Meanwhile, through the study of physical care
skills for schizophrenia patients, Arashi (2009) found that physical care in the remission
phase substituted for the function of their physical sense, promoted recovery of the
sense, and built a bridge across the divide of mind and body.
These results suggested that physical care gives patients with residual schizophrenia
a sense of security and helps them bridge the split between their mind and body. There
is a possibility that physical care works directly on their vulnerable ego functions,
leading to the recovery of their schizophrenic symptoms.
In Japan, complementary and alternative medicine has become popular.
Complementary and alternative medicine, which includes physical care such as
massaging, has been used in the field when western medicine has not been effective
enough (National Center for Complementary and Alternative Medicine). There have
been multiple reports on the effects of massage, including pain relief (Degirmen et al.,

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2010) and stress reduction (Hayes and Cox, 1999), as well as a relaxation (Lu et al.,
2010) and healing effect (Cronfalk et al., 2009). It has been reported that the
combination of a foot bath with massage enhanced relaxation effect even more (Nitta et

MANUSCRIPT
al., 2002; Hattori et al., 2003; Kudo et al., 2006).
In psychiatric nursing care, studies on the effects of massage have reported
improvement in communication and self-care (Fukami, 2009; Uehara and Nishioka,
2010). However, there are few previous studies that clarified the condition of the
intervention method, the procedure of the foot bath and massage or the evaluation
index.
In this study we provided residual schizophrenia patients with foot baths and
massages, and made them feel physiologically relaxed, in order to determine whether or
not the foot bath and massage brought about their subjective comfort. Furthermore, we
examined whether the foot bath and massage improved their psychiatric symptoms and
reduced the difficulties associated with their psychiatric symptoms.

METHODS
DEFINITION OF TERMS
Residual schizophrenia
Residual schizophrenia patients in this study mean patients with negative
symptoms that are prominent after the acute phase symptoms disappear,
characterized by blunted emotion, lack in harmonious relationships with others, and
a lowered interest in surroundings

RESEARCH METHODS
Research Design
A quasi-experimental design was used to conduct “pre-post testing” in a single group
(Figure 1).

Duration of Research
For 11 months from April 2012 through February 2013.
Research subjects
Subjects in this study were 10 patients who were hospitalized in a recuperation ward
at a psychiatric hospital and diagnosed with residual schizophrenia, in accordance with
diagnostic criteria defined in Diagnostic and Statistical Manual of Mental Disorders
fourth revised edition (DSM-IV-TR). We selected these patients because we made a
decision that no disadvantages such as, deterioration of symptoms or decline in

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quality of life (QOL) would affect them even if they participated in this research.

Assessed for eligibility 1.aged≧18 years

Residual schizophrenia

MANUSCRIPT
providing written informed consent.
Excluded from participating if they had
evidence of skin infection or skin tears on
one or both feet.
Explanation of the study(n=10)

Agree( ｎ =6) Excluded( ｎ =4)

---------------------------------------Three times a week for 4 weeks-------------------------------------

PANSS QLS
Before intervention

Heart Beat Fluctuation Analyzer

Foot Bath and Foot Massage Numeric Rating Scale

Utterance expressing comfort during foot bath and massage

Medical record
PANSS QLS

After intervention

Figure 1. Study design

Pretest
As the researchers who implemented foot care were not qualified to perform foot
care, before starting the research, they conducted a pretest of foot massage on six
healthy adults based on the protocol prepared by themselves, and confirmed the comfort
of foot massage.
Procedure for obtaining subjects’ consent for research
Since the subjects in our study had little contact with other people, were inactive and
shut themselves away, the researchers visited the hospital and greeted the patients
three times a week to let them recognize our presence during a 1-month research
preparatory period. We even gave foot baths and massages to other patients who
volunteered. Thus we made every effort to let them know that we visited the hospital
for research and were capable of providing them with foot baths and massages as
nursing care.
Procedure for Foot Bath and Foot Massage

Foot massage in foot bath

Rest (5 min) Foot bath (10 min) Rest (5 min)

Foot massage (each leg 4 min)

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Time

IPT
Body region
1 min
Leg
1 min
Sole
1 min
Dorsum of foot
1 min
Leg

M Figure 2. Foot bath and foot massage timeline

The patients were kept in a semi-upright sitting position on a chair with the top
part of the seat tilted back by 40 degrees and rested with their knees covered by
bath towels for 5 minutes before the foot bath and foot massage intervention. They
then immersed their feet in 40°C water in foot bath vessels for 10 minutes. For 2
minutes within the period, we gave them foot massages in the vessels. After the foot
massage, we wiped their legs with towels and applied baby oil from their knees to
feet. Then we gave an effleurage massage on each of their legs for 4 minutes, or 8
minutes in total. After the massage, we let them rest for 5 minutes. Researchers
themselves performed the massage with the method based on a previous study
(Kimura et al., 2003) three times a week for 4 weeks, or 12 times in all (Figure 2).
We performed the foot bath and massage in a private room where nobody came and
went. During the intervention, we tried not to talk to the subjects, but if they began
to talk to us, we answered. We chose the time for foot bath and foot massage to be
between 14:00 and 16:00, when we assumed that their bath time or activities would
not be affected. In the case that bruises or flares appeared on their legs, or if the
subjects looked tense, we stopped the intervention.
 ACCEPTED
Evaluation methods
Relaxation effect on subjects during the foot bath and foot massage
We used the following indexes to evaluate psychological and subjective relaxation

MANUSCRIPT
effects of foot bath and foot massage. All analyses were done using SPSS software (ver.
20) with a significance level set at 0.05.
Heart Beat Fluctuation Analyzer
As a physiological index, we attached a wireless biosensor (RF-ECG) of a GMS
product to the subjects during foot bath and massage three times a week (Monday,
Thursday, Friday). Then we examined the data obtained from a heart rate variability
real time analysis program as well as every 2 second-sequential change of HF by
calculating the average data over each 2 minute period, obtained 2 minutes after the
start of each section—pre-rest, foot bath, foot massage and post-rest. We used ANOVA
(analysis of variance) with Bonferroni corrections to compare the obtained data. In
addition, we compared and examined the difference in scores between each section for
each individual subject.
Numeric Rating Scale
A numeric rating scale was used as a subjective index for relaxation. The subjects
were asked to select a level of comfort from 0 to 11 before the start of every foot
bath and massage intervention and after the completion.
We calculated the average scores on a Numeric Rating Scale before and after the foot
bath and massage. We compared the difference in scores before and after the foot bath
and massage for each subject by using a paired t-test.
Utterance expressing comfort during foot bath and massage
We recorded what the subjects said during the foot bath and massage on an IC
recorder and made a verbatim written record of their speech. From these recordings, we
extracted the instances expressing comfort from the foot bath and massage.
Changes in the subjects’ psychiatric symptoms and daily life difficulties caused by
psychiatric symptoms after foot bath and massage
In order to assess changes in subjects’ psychiatric symptoms and daily life difficulties
caused by the psychiatric symptoms after foot bath and massage, we used the following
indexes.
Medical record
The information from the start and end of foot care was collected from nursing and
medical records.
 ACCEPTED
Positive and Negative Syndrome Scale
We used the Positive and Negative Syndrome Scale (PANSS) to measure psychiatric
symptoms. PANSS consists of Positive Syndrome measures (7 items), such as delusions

MANUSCRIPT
and hyperactivity Negative Syndrome measures (7 items), such as emotional
withdrawal and blunted affect, and General Psychopathology measures (16 items), such
as anxiety. We measured their symptom severity within one week before the start of
foot bath and massage intervention and then again within one week after the end of the
same intervention. We compared the difference in total score before and after the
intervention by using the Wilcoxon signed-rank test. We also examined the change in
contents of each sub item for individual subjects in every case study.
Quality of life
We used the Quality of Life Scale (QLS) to evaluate daily life difficulties
associated with the subjects’ deficit symptoms. The Quality of Life Scale consists
of 21 items—interpersonal relations (8 items), instrumental role (4 items),
intrapsychic foundation (7 items), and common objects and activities (2 items). We
rated quality of life on the day before the beginning and on the last day of the foot
bath and massage intervention. We compared the difference in total score between
before and after the intervention as well as the difference in score between each sub
item with Wilcoxon signed-rank tests. In addition, we examined how the contents
changed in each sub item for individual subjects in every case study.
Ethical considerations
Research was conducted after receiving approval from the Ethical Review Board
of Meio University, Nago. The purpose and method of this research, as well as the
ethical consideration to subjects, were orally explained using a written document.
During this presentation, board members were given the opportunity to touch the
foot bath vessel and heart rate variability device to be used for our study and also
understand how safe they were. Furthermore, it was explained that whether or not
patients cooperated with the research depended on them, and they could refuse to do
so at any time. Also, privacy protection, the advantages and disadvantages to the
patients that might occur due to a subject’s research participation and the
publication of research results were discussed before obtaining consent. For
subjects under Medical Care and Protection by Mental Health and Welfare of the
Person with Mental Disorder, the same explanation was given to the subjects’
appointed guardians to obtain their consent.
RESULTS
 Participant information
Our research field was a private psychiatric hospital with 190 beds in B

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Prefecture. The subjects who agreed to participate in this research were four males
(66.2±5.4 ages) and two females (55.5±10.5 ages). Their total hospitalization
periods ranged from 2 to 32 years. According to the Global Assessment of

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Functioning (GAF), which is designed to evaluate overall psychological, social, and
occupational functioning, they were rated as being severely impaired (between 21
and 50). The average value of CP equivalent dose was 869.3 mg (±272.7) (Table
1).

Table 1. Participant information

Stay
Case Age Sex Underlying disease GAF CP Equivalent Dose
(years)

1 70s Male Schizophrenia 14 21-30 703 mg

2 60s Female Schizophrenia 30 31-40 450 mg

3 40s Female Schizophrenia, diabetes 17 31-40 1250 mg

4 70s Male Schizophrenia 2 41-50 863 mg

5 60s Male Schizophrenia 32 31-40 1000 mg

6 50s Male Schizophrenia 25 41-50 950 mg

Physiological evaluation of the subjects’ relaxation during foot bath and foot
massage
Change of the heart rate variability

The heat rate in Case 1 shows that it decreased as time went by through the process
of foot bath, foot massage and post-rest compared with that of the pre-rest (p<0.05).
The HR of Case 2 shows that it decreased as time went by through the process of foot
bath, foot massage and post-rest compared with that of the pre-rest (p<1.05). The HR of
Case 3 shows that it decreased as time went by through the process of foot bath, foot
massage and post-rest compared with that of the pre-rest (p<0.05). The HR of Case 4
shows that it decreased as time went by through the process of foot bath, foot massage
and post-rest compared with that of the pre-rest (p<0.05). The HR of Case 5 shows that
it decreased as time went by through the process of foot bath, foot massage and post-
rest compared with that of the pre-rest p<0.05). The HR of Case 6 shows that it
decreased as time went by through the process of foot bath, foot massage and post-rest
compared with that of the pre-rest (p<0.05).
The HF component significantly increased in cases 2 and 3 during foot bath, foot
massage and post-rest, compared to the period before the foot care intervention. On
the other hand, the HF component decreased in cases 4 and 6 during foot bath but

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significantly increased during massage (p<0.05). In case 1, the HF component in
case 1 got lower during foot massage than at pre-rest; however, no change was
observed after that. There was no change in the HF component found in case 5

MANUSCRIPT
during foot bath, massage, and post-rest.

Change of subjective indicator for subjects’ relaxation

Change of subjects’ NRS
Table 2 shows the change in the NRS values before and after 12-time foot care
interventions in all six cases. NRS values in four of the cases significantly increased
from the first foot care intervention ( p<0.05). The NRS values in case 4 increased from
the second foot care intervention until the end, while the values increased after the
third intervention until the end in case 5 (Table 2).

Table 2. Difference in NRS values measured before and after the foot care (n＝6)

Case Baseline After Intervention

t-Value (df) p-Value
Mean (SD) Mean (SD)
1 6.25 (3.57) 9.13 (1.73) 2.636 (11) 0.02
2 6.42 (2.02) 9.83 (0.58) 5.992 (11) 0.00
3 6.00 (1.86) 8.75 (0.97) 5.745 (11) 0.00
4 3.92 (1.31) 5.08 (1.93) 1.680 (11) 0.12
5 4.67 (1.72) 5.33 (1.15) 1.076 (11) 0.31
6 4.92 (1.00) 7.58 (2.06) 6.169 (11) 0.00
(p-value: paired t-test)

Subjects expressing their comfort during the foot care

Case 1 expressed his desire to have the period of time allotted for foot care extended,
by asking, “Could you extend the time?” and also said, “I feel so happy that I could
almost cry.” Case 2 said, “I feel better.” Case 3 said, “I feel comfortable.” and “I feel
like sleeping.” She also suggested that the same treatment be recommended for others,
by commenting, “It would be good for elderly people because it is so comfortable.”
Case 5 said after the foot care, “My feet felt light,” while case 6 said, “I can walk
easily” and “I feel so good.” Case 4, however, did not mention any comfortable
feelings.
Change of psychiatric symptoms
 Change of subjects’ PANSS
Subjects were measured using the Negative Syndrome Scale before and after foot

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care was performed. The mean score before was 29.0, which lowered to 21.5 after,
indicating that foot care improved their negative symptoms ( p<0.05). The score rated
by the General Psychopathology Scale was 37.0 before the foot care intervention, but

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lowered to 32.5 after the foot care, also showing improvement (p<0.05). There was no
significant difference in scores on the Positive Syndrome Scale (15.0 before the foot
care and 13.8 after; p=0.14) (Table 3).
Table 3. Difference in values before and after foot care by the Positive and Negative Syndrome Scale
(n=6)

Scale Stage Median (Mean) Range ｚ-value p-value

(Min-Max)
Positive scale Before 15.0 (16.17) 10-25
1.46 0.14
After 13.8 (13.50) 9-19
Negative scale Before 29.0 (29.67) 20-40
2.20 0.03
After 21.5 (20.33) 13-27
General Psychopathology scale Before 37.0 (37.83) 34-43
1.57 0.04
After 32.5 (33.00) 28-42
(p-value: Wilcoxon signed-rank test)

Change of subjects’ QLS（Quality of Life Scale)

Table 4. Difference in values before and after foot care by the Quality of Life Scale (n=6)

Factor Stage Median Range ｚ-value p-value

(Mean) (Min-Max)

Interpersonal relations Before 1.5 (2.7) 0-9

I 2.03 0.04
and social network After 6.5 (12.2) 4-26
Role accomplishment such ― ― ―
II
as the work ―
Before 7.0 (7.2) 2-16
III Intrapsychic foundations 2.23 0.03
After 22.0 (22.8) 4-37

Concerning common objects Before 3.5 (3.2) 20-4

IV 1.75 0.08
and activities After 6.0 (6.5) 2-12
Before 10.50 (13.2) 8-29
Total Score 2.20 0.02
After 34.00 (41.2) 10-73

(p-value: Wilcoxon signed-rank test)

The mean total score for all six subjects, rated by QLS before the foot care
intervention, was 10.5 and increased to 34.0 after the intervention, indicating
improvement in their quality of life (p<0.05)
The median value of 1.5 in interpersonal relations and social network, a factor item
of QLS, before foot care increased to 6.5 after the intervention (p<0.05). The
median value
of “social withdrawal”, a sub-item of interpersonal relations and social networks,
increased significantly (p<0.05). The median value of 7.0 in intrapsychic foundations

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before the foot care intervention increased to 22.0 after the last intervention ( p<0.05).
The value of three sub-items, such as “a sense of purpose”, “motivation”, and “inability
to experience pleasure” decreased significantly (p<0.05). For common objects and

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activities, the median value of 3.5 before the foot care intervention increased to 4.1 after
the intervention (p=0.08), but no significant difference was observed (Table 4).

Changes in Subjects’ Self-care

The changes in subjects from the start of foot care intervention to the completion
were described as follows:
Case 1: The subject had pain in the left knee and had to be in a wheelchair before
the start of foot care intervention. However, he started practicing to walk by himself
four weeks after the start of foot care intervention and became able to go to the
toilet by foot. He refused to take a bath and would not change clothes for several
days, so he was in an unsanitary condition. However, he became able to change
socks by himself and asked the researchers to wash his clothes after the fourth
week.Case 2: The subject was under a delusion and withdrew to his own room
before foot care intervention. However, a week after the start of foot care
intervention, he said to a nurse that he wanted to go to the hospital stores.Case 3:
The subject was under such a strong delusion and had so many hallucinations that
he spent most of his time in the laundry room without any purpose, isolating
himself from others, but now he only stays there to do laundry. Although he only
rarely participated in occupational therapy before foot care intervention, he
suddenly began to participate in it a week after the start of intervention.Case 4: No
dramatic change was observed in the subject’s self-care.Case 5: The subject spent
most of his time lying in bed before foot care intervention. However, from the
fourth intervention, his activities increased, including picking up flowers and grass,
taking walks in the garden of the hospital, and watching TV in the lounge
room.Case 6: Although there was absolutely no communication with family
members before foot care intervention, the subject said “I will go back home” after
the eleventh intervention and called his elder brother’s home to consulting him about
it.

DISCUSSION
Relaxation effect produced by foot baths and massages on residual schizophrenia
patients
parasympathetic nerve activity
heart rate and HF
The heart rates significantly decreased after foot care intervention compared with

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those pre-rest in all cases; heart rate increases with the tension of sympathetic
nerves and decrease with the tension of parasympathetic nerves.
In this study, a decrease in parasympathetic nerve activity was observed in every

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case, indicating a relaxation effect. These results are in line with a study by Nitta et
al. (2002) in which 10 elderly subjects who each submitted to a 5-minute foot bath
and subsequent foot massage had their heart rates measured as an index of the
relaxation effect. Their heart rates were shown to have significantly decreased
following the treatment indicating that a relaxation effect was produced. In the field
of psychiatric nursing care, only a study conducted by Motohashi et al. (2008)
investigated the relaxation effect as measured from heart rates. That study reported
that after schizophrenia patients were given one-month of intensive foot care, their
heart rates decreased, showing its relaxation effect. In our research, however, we
identified the relaxation effect only on residual schizophrenia patients by giving
them a clinically feasible frequency of intervention.
On the other hand, HF usually increases by acceleration of the heart via
parasympathetic nervous system activities. In this study, the HF in cases 2 and 3 also
significantly increased at all interventions from foot bath through the end, which
verified the effect of relaxation. In addition, the HF in cases 4 and 6 did not change
after the foot bath, but started increasing during the massage and continued to
increase until the procedure ended. According to Shimizu et al. (2002), the
parasympathetic nervous system temporarily inhibited activity of the heart at the
start of the foot bath. After that, the acceleration of the heart’s parasympathetic
nervous activities, as well as the inhibition of sympathetic nervous system
activities, occurred during the foot bath, which led to a relaxation effect. Since cases
4 and 5 had a similar change to what was reported by Shimizu, we predicted that the
foot bath and massage brought about a relaxation effect. Concerning case 1, which
showed little increase in HF, the HF decreased once during the foot bath and
increased after that, but no significant change was observed compared to pre-rest.
We believe that this may have been due to the subject’s tendency to suddenly start
shouting or singing, making sympathetic nervous system activity more predominant.
Hayashi (1999) reported that smoking decreased HF components, which we believe
may explain case 5. The mean value of HF components measured each time was
somewhere between 1.1 and 14.4, showing that the difference varied from day to
day. It was probably because he had a smoking habit, which we think likely affected
his HF values. Nevertheless, in the present study, we did not ask patients
to change their lifestyle habits for the sake of the research, given the limits of what we
could do and the issues of their consent.

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In conclusion, apart from our study, we could not find any other study in Japan
that examined an intervention for patients with psychiatric disorders using HF. Our
study, however, identified a relaxation effect in four cases.

Subjective relaxation effect MANUSCRIPT

In all cases after the foot bath and massage intervention, the NRS scores increased; a
significant increase was observed in four cases, indicating that the subjects had feelings
of comfort. Nitta et al. (2002) and Kudo et al. (2006), who gave a simple massage to 20
healthy females after a foot bath, used five levels of NRS to evaluate their comfort and
reported that the group in the foot care intervention showed a much higher comfort
level than the control participants. Although there was a slight difference in the length
of intervention and method between the two studies, we had similar results. It was
confirmed that foot baths and massages were the care that brought about feelings of
comfort to the patients with residual schizophrenia. Moreover, Nitta et al. (2004)
pointed out the importance of not only physiological relaxation, but also the
patients’ utterances expressing their subjective satisfaction during or after the foot care.
In this study, during the foot care we heard the subjects make comments such as “Could
you extend the time?” and “Time flies. I can’t believe it’s over now,” leading to our
realization that they wanted to extend the length of time for the care. We also
recognized that the foot baths and massages were comfortable for them, because some
of them said, “I feel comfortable” and “I feel so happy that I could almost cry”. In
addition, in anticipation of the care, some of them had already taken off their socks and
were waiting for the foot bath and massage by the time the researchers came. All
subjects, except for case 4, said something to express their subjective feelings of
comfort, which had never happened before in daily conversations between the nurses
and patients. A previous study reported that there was an increase in voices expressing
comfort after the researchers had examined what patients were saying during the foot
bath and massage (Kobatake, 2005; Motohashi et al., 2008). In the area of psychiatric
nursing care, there seemed to be no prior literature in which an evaluation scale was
used. We could identify the patients’ feelings, judging from both the scale to evaluate
comfort and their voices expressing feelings of comfort. These results, therefore,
suggest that foot baths and massages bring about subjective comfort for residual
schizophrenia patients.

The effect of foot baths and massages on the improvement of psychiatric symptoms
 In order to clarify whether or not foot baths and massages as nursing support were
effective in improving residual schizophrenia patients’ psychiatric symptoms, we

ACCEPTED
investigated the change in their PANSS scores within a week before the start of foot
bath and massage intervention and within a week after the last day. There were
significant improvements in both the negative and general symptoms. In particular,

MANUSCRIPT
scores concerning negative symptoms in all cases increased after foot bathing and
massaging. During the research we provided the subjects with ordinary psychotherapy
as well as nursing care. There was no change in the antipsychotic drugs prescribed to
the patients. This allows us to conclude that the foot baths and massages were effective
in improving the negative symptoms of patients with residual schizophrenia.
In previous studies where PANSS was also used as an evaluation index for
improvement in symptoms of residual schizophrenia patients (Saeki et al., 2006;
Miki et al., 2007; Nakamura et al., 2007), researchers aimed to alleviate their
psychiatric symptoms by conducting psychiatric rehabilitation, occupational
therapy, and educational psychology, based on group therapy. These were all
intervention methods that require special training. Meanwhile, there was only one
case study regarding the effect of foot baths and massages. In this previous study, in
which the subjects were patients with treatment-resistant schizophrenia, the
researchers aimed to evaluate psychiatric symptom changes created by daily nursing
care provided by nurses (Motohashi et al., 2008). On the other hand, in the current
study, in which the subjects were only residual schizophrenia patients, we could
determine that their negative symptoms were improved by giving them foot baths
and massages, based on a quasi-experimental research design.
In general, residual schizophrenia patients with strong deficit symptoms were not
willing to participate in psychiatric rehabilitation programs despite nurses in the
hospital ward frequently trying to introduce the programs. As a result, the patients were
isolated and shut themselves away in many cases (Deguchi, 1999). The current study,
however, found that their symptoms, such as “being passive/social withdrawal due to a
loss of motivation” and “emotional withdrawal,” were improved by providing them
with foot baths and massages as daily life support from nurses. In some cases, patients
even voluntarily participated in the ward recreation, becoming more interested in their
daily lives and more independent-minded. For this reason, we suggest that foot baths
and massages as nursing care support with a one-to-one relationship between a nurse
and a patient are a means to enhance the patient’s interest in a psychiatric rehabilitation
program and urge them to participate.
Gomibuchi (1983) and Kinoshita (1994) have suggested that, because the correlation
between mind and body was destroyed in schizophrenia, a body-focused approach for
patients with schizophrenia should give a good influence on recovery of their mind—

ACCEPTED
body relationship. Arashi (2009), who examined the relationship between the recovery
of schizophrenia and physical care skills, reported that through physical care for
residual schizophrenia patients by nurses, patients could physically feel the nurse. This

MANUSCRIPT
would promote the recovery of the patient’ physical sense, help build a bridge across
the divide of mind and body, and eventually contribute to their recovery from
schizophrenia.
Since we could see significant improvement in negative and general symptoms, we
predicted that patients could physically feel the nurse through the physical touch of foot
baths and massages, so that patients themselves could recover a physical sense of their
own and have a sense of reality. In other words, physical care helped schizophrenia
patients recover the relationship between their split mind and body, leading to an
improvement in their psychiatric symptoms.

The effect of foot bath and foot massage on daily life difficulties faced by residual
schizophrenia patients
In order to find out whether or not foot baths and massages reduce residual
schizophrenia patients’ daily life difficulties caused by their psychiatric symptoms, we
examined QLS scores on the day prior to the beginning of the foot care intervention and
the last day. Since improvement in their quality of life was observed with the
intervention of foot bath and massage in this study, daily life troubles associated with
psychiatric symptoms were lessened by foot bath and massage.
In previous research similar to ours, there were a number of case studies, which
compared between pre and post interventions by using check lists (Motohashi et al. ，
2008), keeping nursing records (Miyaji and Hujita, 2004; Fukami, 2009) and observing
(Uehara and Nishioka ，2010), in order to examine the patients’ quality of life. These
reports referred to the improvement of patients’ self-care and communication abilities,
but none examined patients’ quality of life using a standardized scale. In this study, we
used a standardized scale and investigated the daily life problems caused by psychiatric
symptoms. An improvement in quality of life was observed in all cases.
A change in daily life difficulties was identified in five cases by comparing
individual QLS scores before and after intervention. Before foot care intervention,
case 1 had been confined to bed and lived an idle life almost all the time. However,
a week after the start of foot bath and foot massage, he voluntarily started walking
exercises and was eventually able to walk. He even expressed hope by saying, “I
would like to go home.” or
“I would like to have my own family just once.” In the other cases (2, 3, 5 and 6),
they likewise voluntarily participated in occupational therapy or took a walk in the

ACCEPTED
garden, and seldom shut themselves away after the intervention. Since the subjects
in our study had been rarely visited by their families, kept to themselves, and had
little contact with other people, nurses in the hospital ward had found it difficult to

MANUSCRIPT
be involved with them. For this reason, they had been isolated. However, after the
researchers became involved in the patients and shared the same time and place
with them by giving them foot baths and massages, they came to express their
desires in a period of time as short as 4 weeks. As a result, their daily life problems
were reduced.
According to Arashi (2009), nurses could be registered as non-threatening by
residual schizophrenia patients by directly working on their lowered ego functions
and physically taking care of them. They then could play a role in protecting and
supporting the patients’ egos. Furthermore, Terasawa (2004) mentioned that
massage, which directly worked on their “skin-ego”, would bring the patients a
sense of security that they were enveloped in skin touching, so that it could help
vulnerable patients to promote the recovery of their ego functions. Since the
subjects in this study were chronic residual schizophrenia patients with lowered ego
functions as Arashi pointed out, it was predicted that such physical care as foot
bathing and massaging protected their lowered ego functions, which led to the
recovery of their ego functions.
In this research, because the patients continuously received foot care intervention,
they became able to express their hopes and motivations to researchers, so “sense of
purpose” and “motivation”, sub-items of QLS, significantly improved.
In short, revealed that the patients accepted the nurses, who performed foot baths
and massages as not threatening but caring for them. It was probably because the
patients sensed that the nurses paid attention to them, which led to their interactive
relationship between them. According to Koitabashi (2009), nurses sent the
message that they were really concerned about the patients by directly touching
them, so that a relationship of mutual trust was developed. In addition, Kawashima
(2009) said that patients could feel that they were supported, encouraged and also
empathetically concerned by nurses sincerely touching the patients with their hands.
In other words, physical care made the patients feel that they were cared about and
supported by other people, so that their motivation was enhanced and they were able to
act on their own will.
Nakai (2001) reported that caregivers needed to patiently wait for changes because
residual schizophrenia patients show little progress in their symptoms. In this study,
however, the subjects showed improvement in motivation from the early stage of the
research; in a period of time as short as 4 weeks, the QLS scores in all of the subjects
increased. Therefore, it was suggested that foot bath and foot massage as nursing care

ACCEPTED
skills are effective in relieving the daily life difficulties caused by psychiatric
symptoms. LIMITATION
This study indicated that foot baths and massages for residual schizophrenia

MANUSCRIPT
patients were effective by using a quasi-experimental research design on a single
group in a pre and pro test configuration. In the future, in order to enhance the
evidence level, we need to increase the number of subjects and conduct a
Randomized Controlled Trial (RCT) to investigate the effectiveness of foot baths
and massages.

COMPETING INTERESTS
All authors declare that they have no competing interests.

ACKNOWLEDGMENTS
The authors are deeply thankful to the following people who cooperated and
assisted with this research. Dr. Une Takaishi and the Nursing Staff of the Noble
Medical Center. Meio University Psychiatric Nursing Faculty and staff.
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LAMPIRAN SOP TERAPI RENDAM KAKI DAN PIJAT KAKI PADA
PASIEN DENGAN RESIDUAL SKIZOFRENIA
Pengertian Terapi rendam kaki dan pijat kaki merupakan salah satu
terapi komplementer dengan melakukan perendaman
kaki dalam air hangat serta melakukan pemijatan untuk
mengatasi gejala gangguan psikologis.
Tujuan Memperbaiki gejala psikologis negatif serta
meningkatkan kualitas hidup pasien dengan residual
skizofrenia.
Indikasi  Pasien dengan stress, cemas, insomnia
 Pasien dengan takikardi
 Pasien dengan hipertensi
 Pasien dengan residual skizofrenia
 Pasien dengan kualitas hidup rendah
 Pasien dengan edema pada kaki
 Pasien dengan nyeri sendi
Kontra indikasi  Pasien dengan infeksi kulit
 Pasien dengan luka terbuka pada kaki
 Pasien dengan kelainan jantung tidak terkompensasi
Hal yang perlu Terapi ini dilakukan di ruangan yang dapat menjaga
diperhatikan privasi pasien sehingga pasien merasa lebih nyaman.
Waktu terapi dilakukan yaitu pukul 14.00 – 16.00 WIB
selama 3 kali seminggu dalam 4 minggu.
TINDAKAN
Tahap Pre Interaksi
1 Kesiapan diri sebelum terapi, observasi catatan perkembangan klien
2 Persiapkan alat dan bahan :
 Baskom
 Handuk
 Air hangat
 Termometer air
 Baby oil
 Bantal
  Stopwatch
 Perlak
3 Persiapan pasien seperti menggunakan pakaian yang longgar atau tidak
ketat
Tahap Orientasi
4 Memberikan salam
5 Memperkenalkan diri
6 Membina hubungan saling percaya
7 Menjelaskan tujuan, prosedur tindakan, lama tindakan, persetujuan,
memberikan kesempatan klien bertanya sebelum melakukan tindakan
Tahap Kerja
8 Minta pasien untuk mencuci kaki dengan air
9 Memposisikan pasien dengan posisi duduk semi tegak di kursi dengan
bagian atas kursi dimiringkan ke belakang 40 derajat dan diistirahatkan
dengan lutut ditutupi oleh handuk mandi
10 Istirahatkan pasien selama 5 menit
11 Campurkan air hangat dan air dingin ke dalam baskom
12 Ukur suhu air dalam baskom menggunakan termometer air. Tambahkan
air hangat jika suhu air masih di bawah 400 C dan tambahkan air dingin
jika suhu air di atas 400 C.
13 Kemudian minta pasien memasukan kedua kakinya ke dalam baskom
dan tutup menggunakan handuk. Kemudian rendam selama 10 menit.
14 Saat 2 menit terakhir selama waktu perendaman, pijat kaki pasien dalam
baskom selama 2 menit.
15 Angkat kaki pasien dan letakan di letakkan di atas perlak berisi handuk.
Kemudian keringkan kaki menggunakan handuk. Setelah itu, oleskan
baby oil ke kaki pasien.
16 Lakukan pemijatan dengan teknik effleurage pada masing-masing kaki
selama 4 menit secara bergantian. Pemijatan dilakukan menuju arah
jantung.
17 Pemijatan dimulai dengan memijat bagian tungkai selama 1 menit,
kemudian dilanjutkan pada bagian telapak kaki selama 1 manit. Setelah
itu, lakukan pemijatan pada punggung kaki selama 1 menit. Selanjutnya,
lakukan Kembali pemijatan pada tungkai kaki.
18 Istirahatkan kembali pasien selama 5 menit.
Tahap Terminasi
19 Evaluasi respon terhadap terapi baik secara subjektif maupun objektif

20 Membuat kontrak selanjutnya

21 Mengakhiri kontrak dengan pasien
22 Dokumentasikan hasil kegiatan