DE GRUYTER Journal of Complementary and Integrative Medicine.

2018; 20170183

Sudabeh Ahmadidarrehsima1 / Reza Mohammadpourhodki2 / Hossein Ebrahimi2 /

Maryam Keramati3 / Mostafa Dianatinasab4

Effect of foot reflexology and slow stroke back

massage on the severity of fatigue in patients
undergoing hemodialysis: A semi-experimental
study
1 Department of Nursing and Midwifery, Jiroft University of Medical Sciences, Jiroft, Iran
2 School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran, E-mail: rezamdpoor@gmail.com.

http://orcid.org/0000-0001-5677-0133.
3 School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
4 Shiraz HIV/AIDS Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran.

http://orcid.org/0000-0002-0185-5807.

Abstract:
Background: Fatigue Is One Of The Most disturbing and the most common symptoms reported by patients
dialyzed, there are methods available on Complementary and Alternative Medicine, through which nurses
can help their patients to promote health. Reflexology is a treatment that which has a long history and one of
the most popular and the most widespread method of alternative medicine. In this study, the effects of foot
reflexology and slow stroke back massage on the severity of fatigue in patients treated with hemodialysis.
Methods: This study is a quasi-experimental that performed on 52 patient chosen from Imam Khomeini dialysis
center in Zabol and devised into control and intervention groups by randomized method. Required information
collected from a demographic and fatigue severity questionnaire. After completing questionnaires by the study
subjects, Foot massage and slow stroke back massage, was performed during the three weeks, two sessions
each week (5 sessions totally). After the end of the third week fatigue set the scale to be completed by both
groups. Data were analyzed using Independent t-Test, Chi-squared test, Fisher exact test, two-way ANOVA
with repeated measures and Bonferroni test by SPSS software version 21.
Results: The mean fatigue in patients with foot reflexology massage and slow stroke back massage reflect
on the 53/61±10/12and 52/2±10/37, and the differences were not but after the intervention fatigue in the
Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd

group receiving foot reflexology massage was reduced significantly compared to Slow stroke back massage
group(p<0.0001).
Conclusions: the result of this study showed reflexology massage is a safe and economical nursing interaction
for decreasing fatigue in hemodialysis patients
Keywords: fatigue, foot massage, hemodialysis, slow stroke back massage
DOI: 10.1515/jcim-2017-0183
Received: December 29, 2017; Accepted: March 21, 2018

Introduction
Incidence and prevalence of chronic kidney disease in the world, including Iran are growing and have now be-
come a threat and global health problem [1]. At the end of 2004, there were about 400,000 patients with chronic
renal failure in America among whom more than 300,000 patients have been treated with hemodialysis [2].
Chronic kidney diseases are among diseases that not only threat physical health but also jeopardize other as-
pects of health. Nowadays, if these patients do not successfully receive a kidney, they avoid from premature
death using modern methods of treatment, including hemodialysis, and yet, caught the whole range of phys-
ical, psychological, social and economic difficulties [3 and 4]. Fatigue is one of the most troubling and most
common symptoms reported by dialyzed patients [5]. Fatigue decreases well-being in these patients [6]. There
are numerous methods, including methods in complementary and alternative medicine through which nurses
can help their patients promote health. Reflexology is a complementary and alternative therapy with a long
Reza Mohammadpourhodki is the corresponding author.
© 2018 Walter de Gruyter GmbH, Berlin/Boston.

Brought to you by | University of California - Santa Barbara

Authenticated 1
Download Date | 9/30/18 5:14 PM
 Ahmadidarrehsima et al. DE GRUYTER

history and it is now one of six adjunctive treatments in America. This method is one of the most popular and
the most widespread methods of alternative medicine [7]. Ferrer writes: reflexology is a strong massage in cer-
tain areas of the body that can be effective in relieving and eliminating of physiological disorders, and provides
peace and relaxation in the final organs of the body [8]. There are many methods, including those are available
in CAM which nurses can help their patients through these methods to improve their health. Massage therapy
is one of the most popular alternative and complementary therapy that is used in nursing and easy to imple-
ment, safe, noninvasive and relatively cheap [9]. Reflexology of feet is as follows: after the mild massage of foot,
feet heel is hold with the left hand and flexion it from the plantar ankle and then put a pressure directly to the
solar plexus by right thumb [10]. So reflexology is one of the actions that can be used as a nursing intervention
to reduce fatigue [11]. Slow stroke massage in the back occurs with slow, rhythmic and gentle movements of
hands on the patient’s back, moving with a speed of about 60 min that takes about 3–10 min. Movements used in
this type of massage are slow stroke with sensational perception and has a very beneficial effect in patients [12].
In many investigations, foot reflexology massage has been investigated as a nursing noninvasive intervention
in different conditions, including the ability to improve anxiety in cancer patients undergoing chemotherapy
[13], decrease depression and improve immune function [14], pain relief [15], fatigue [16], reducing the symp-
toms of asthma [17] and multiple sclerosis [18]. Concerning the slow stroke back massage, some notes that this
technique is an easy, inexpensive, rapid, noninvasive and nondrug nursing intervention [19]. With regard to
the fact that a variety of studies have been conducted in foot reflexology, this study was conducted to compare
the effects of foot massage therapy and slow stroke massage on the back in the severity of fatigue in patients
treated with hemodialysis in Imam Khomeini hospital in Zabol in 2015.

Materials and methods

This research is a quasi-experimental study with two groups (massage and foot massage stroke). In this study,
52 hemodialysis patients referred to Dialysis Center in Imam Khomeini Hospital in Zabol in 2015 were selected
by census. The figure-1 shown the study follow diagram. Inclusion criteria were at least 18 years old, a history
of at least 6 months of dialysis, inclination to participate in the study, three times weekly hemodialysis, each
time 32–4 h, no history of reflexology in the past 6 months, full consciousness, ability to answer questions,
audio acceptable speech, lack of chronic pain and diabetes risk, degree of fatigue based on a fatigue severity
scale [9]. In the case of each of the following conditions during the research, it will be excluded from the study:
the patient death during the study, mental and sensory disorders, kidney transplantation during the study,
the patients quit collaborating with researcher during the study. In order to collect information, two forms
were used [1]: demographic questionnaire on demographic characteristics (age, sex, marital status, blood type,
location, education level) as well as information about the disease, including the duration and two fatigue
Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd

severity scale and history of hemodialysis. Fatigue severity scale is a self-report designed by Crop et al., in 1989
to measure fatigue. The fatigue scores were obtained from patients to respond to nine questions on this scale.
For each question, seven numbers were allocated (from one to seven) and number one is as the lowest and
number seven represents the maximum fatigue and patients chose the desired number due to the fatigue. It
is one of the best and most useful scales of fatigue useful for measuring the severity of fatigue [9]. This scale
is used in most medical research and is now used in dozens of countries, Australia, Britain, Canada, France,
Germany, Spain, New Zealand, Switzerland, Taiwan and America. Its reliability has been confirmed in many
studies by the Rasoulie, Zakerie and Moghaddam [20] and faculty members with 91% and 83% alpha. Its face
and content validity has been confirmed by studies conducted by Ghaffarie, Zakerie, Moghaddam and Bonner
[20–23]. By procedure, the samples were randomly assigned to two groups of blocks into two intervention
and control groups. Block randomization was performed to avoid interference. Patients were allocated in a
randomized block based on the dialysis of individual patients in odd or even days. At first, it was randomly
assigned that the intervention group receive dialysis in even days and the second intervention group for odd
days. To prevent contamination of information (Data contamination) and bias (Bias), start of sampling in next
day was subject to the absence of all of the subjects the day before and in the case of presence of just one unit,
sampling was not performed until its discharge. Then, demographic questionnaire and fatigue scale were given
to them to determine fatigue severity. In foot reflexology group, the process for foot reflexology massage and
duration of the program were described for 26 participants. Foot reflexology was performed for two sessions a
week, each session lasting 30 min and 3 weeks by a female trained researcher. Reflexology stages of this study
were as follows. The unit study was asked to close his eyes and place in a totally relaxed posture. After the mild
massage of foot, feet heel is hold with the left hand and flexion it from the plantar ankle and then put a pressure
directly to the solar plexus by right thumb. This work was performed for 30 min for both feet [24].

Brought to you by | University of California - Santa Barbara

2 Authenticated
Download Date | 9/30/18 5:14 PM
 DE GRUYTER Ahmadidarrehsima et al.

In massage group of slow back stroke, the process for foot reflexology massage and duration of the program
was described for 26 participants and then was performed in three weeks, two sessions per week for five sessions
in a sitting posture by a female trained researcher. The duration of each massage session was 10 min. The
procedure of slow stroke back massage was performed in a sitting position on a chair and bend forward over
a pillow. Shoulders are hold with both hands. While the thumb is on both sides under the skull base, fine
rotational movements are performed under the upper neck and the palm of one hand is placed at the base of
the skull and soft blows to the foot low to the waist on the spine. Then the second hand places at the base of the
skull and taps on the spinal cord in the same way. This is regularly performed. Hands are placed on the sides
of the neck below the ears and some hits down on the collar bone to the shoulder of the person using the right
thumb. The movement is conducted several times. Thumbs are at the both side of spine to the shoulder and will
be moved at the bottom of the spine to the waist. Palm is placed on either side of the neck and continuous and
cache cleaner blows hit down side of the neck, across the shoulders and down the back and behind backbone
[25]. After the end of the third week, fatigue severity scale was completed by both groups. After the completion
of scale in both groups (feet massage and slow stroke back massage), the patient falls in one of the categories
of fatigue, mild, moderate and severe according to the fatigue score. After obtaining the necessary permits r
from the University of Medical Sciences, Zabol, researchers referred to the hospital and then start intervention
after providing explanations needed to samples and written permission. Data for this study were analyzed
using independent t-test, chi-square test, Fisher’s exact test, two-way ANOVA with repeated measures and
Bonferroni test by SPSS software version 16. Informed consent was obtained and the research was approved by
the ethics committee of Zabol University of Medical Sciences. In this study, the full description of the processes
and the importance of the study were explained to the patients who had volunteered and were selected. All of
the assessments were noninvasive.
Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd

Figure 1: The study follow diagram (CONSORT diagram)

Brought to you by | University of California - Santa Barbara

Authenticated 3
Download Date | 9/30/18 5:14 PM
 Ahmadidarrehsima et al. DE GRUYTER

Results
To describe the frequency of data, descriptive statistics were used and independent t-test, chi-square test,
Fisher’s exact test, two-way ANOVA with repeated measures and Bonferroni test were used for comparing
of data. The significance level for all tests was 0/05. The findings of this study showed that patients in the
intervention and control groups were homogeneous in terms of demographic characteristics.
Table -1 presents demographic characteristics of the study participants. Mean fatigue in patients in two
groups of foot massage and slow stroke back massage before performing reflexology massage were 53/61±10/12
and 52/2±10/37, respectively; Masaz and there was no statistically significant differences (p=878% ). After in-
tervention, ANOVA by repeated measures showed that the mean fatigue scores in slow stroke back massage
and foot reflexology after intervention were 37/65±11/51 and 34/08±12/72, respectively and there was a sig-
nificant statistical difference between the two groups(p<0001) (Table 2). Comparison of the mean fatigue scores
in both groups of stroke back massage and foot reflexology in the third week after intervention showed that
the mean score of fatigue in foot reflexology massage was statistically significant to slow stroke back massage
(Table 2).

Table 1: Demographic information of hemodialysis patients in two groups of foot massage and slow stroke back massage.
Group Foot massage Slow stroke back Result
variable massage
Number (%) Number (%)

Age Mean (SD) 47.04 47.42 p=364%

10.573 12.510 t=120%
Df=50
Sex Male 15 21 p=0.071
Female 57.7 80.8
Marital status Single 18 10 p=0.026
Married 69.2 38.5
Blood group A 10 10 p=0.855
38.5 38.5
B 4 3
15.4 11.5
AB 1 3
3.8 11.5
O 11 10
42.3 38.5
Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd

Education level Illiterate 7 17 p=0.015

26.9 65.4
Primary 7 1
26.9 3.8
Diploma 10 6
38.5 23.1
Bachelor 2 2
7.7 7.7
Residential areas Village 11 17 p=0.095
42.3 65.4
City 15 9
57.7 34.6

* T test, Fisher’s exact test ** Chi-square test ***

Table 2: Frequency distribution of mean fatigue scores in two palm reflexology and stroke back massage.
Time Groups One week before the Two weeks before the
intervention intervention.
Food Mean 53.61 34.08 (0<0001)a
reflexology SD 10.12 12.72
Stroke back Mean 52.2 37.65
massage SD 10.37 11.51

Brought to you by | University of California - Santa Barbara

4 Authenticated
Download Date | 9/30/18 5:14 PM
 DE GRUYTER Ahmadidarrehsima et al.

a Two-way analysis of variance with repeated measures.

Discussion
The average severity of fatigue in groups of foot reflexology and slow stroke back massage in the first week
before intervention were 53.61 and 50.30, respectively. Also, the frequency of fatigue in these patients in the
studies by Brown [26], Schneider [5], Weisbord [27], EY [28], Kim [29], Liu [30] and Moortag [38] have been re-
ported 90, 58, 69, 70/63, 77/9, 50 and 0/071, respectively. The difference in fatigue could be due to differences
in behavioral factors, factors associated with treatment and patient characteristics [6]. Reflexology is a comple-
mentary and alternative therapy with a long history and this method is now one of six adjunctive treatments
in America. This method is one of the most popular and the most widespread methods of alternative medicine
[7]. This is a common complaint which is described as vague and unpleasant symptoms [26]. The findings of
this study showed that the mean score of fatigue severity before and after reflexology and stroke back massage
had a significant difference. Comparison of the mean fatigue scores in the two groups of stroke back massage
and foot reflexology in the third week after the intervention showed that the mean score of fatigue in foot re-
flexology massage had a statistically significant decrease over stroke back massage. There were no foreign or
non-foreign studies concerning about the effect of slow stroke back massage, foot massage in reducing fatigue
in hemodialysis patients, but Taghizadeh et al., in a study to compare the effects of reflexology massage and
slow stroke massage on physiological parameters in patients with myocardial infarction showed that stroke
massage had better impact on the mean systolic and diastolic blood pressure, respiration rate, increased ar-
terial oxygen than a reflexology massage [31]. This difference could be due to differences in study groups or
indices. In studies on the effects of massage therapy on other diseases, improvement of fatigue severity has been
reported. For example, Tsay et al., showed that massage therapy improves sleep quality and decrease fatigue
and improves the quality of life in patients with chronic renal failure [32]. Shaerqhadm et al., also showed that
the palm reflexology was effective in reducing fatigue in hemodialysis patients [19]. Lee and Sohng in their
study conducted on 29 patients with pneumoconiosis found that foot reflexology has a significant effect on
fatigue and insomnia [5]. Unlike the results of this study, the results of a study on the effects of massage on
fatigue in cancer patients showed no significant decrease in fatigue immediately after the massage [33] which
the authors of the study believe that one of the most important causes of this issue is that fatigue in cancer
patients usually is chronic, so massage intervention should be used longer.
Considering the results of this study, it is suggested that reflexology as a noninvasive and effective inter-
vention used to improve symptoms of fatigue chronic illness such as kidney dialysis.
Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd

Acknowledgements
We thank all the Faculty of Nursing and Midwifery University of Medical Sciences of Zabol, honorable officials
and all hospital patients.

Author contributions: All the authors have accepted responsibility for the entire content of this submitted
manuscript and approved submission.
Research funding: This paper is the result of a research project at the Zabol University of Medical Sciences
which is sponsored by the university and the support is appreciated.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis,
and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

References
[1] Biniyaz V, Tayebi A, Sadeghi Shermeh M, Ebadi A, Nemati E. The effect of supplementation with intravenous vitamin C on fatigue of
hemodialysis patients. J Crit Care Nurs. 2013;5:145–54.

Brought to you by | University of California - Santa Barbara

Authenticated 5
Download Date | 9/30/18 5:14 PM
 Ahmadidarrehsima et al. DE GRUYTER

[2] Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Texbook of medical-surgical Nursing, 11th ed. Fulfilled by Amazon: Lippincott Williams &
Wilkins, 2008 [https://www.amazon.com/Brunner-Suddarths-Textbook-Medical-Surgical-Nursing/dp/0781759781]
[3] Tayyebi A, Salimi SH, Mahmoudi H, Tadrisi SD. Comparison of quality of life in haemodialysis and renal transplantation pateints. IJCCN.
2010;3:7–8. [In Persian]
[4] Shahdadi H, Mazloum SR, Badakhsh M. Comparison of blood pressure in the supine and semi-Fowler’s position during hemodialysis.
Iran J Nurs Midwifery Res. 2010;23:8–13.
[5] Schneider RA. Chronic renal failure: assessing the Fatigue Severity Scale for use among caregivers. J Clin Nurs. 2004;13:219–25.
[6] Hadian JZ, Aliasgharpoor M. Evaluating the effects of designed exercise program on mean of activity tolerance in hemodialysis patients. J
Shahrekord Unive Med Sci. 2012;14:83–91.
[7] White AR, Williamson J, Hart A, Ernst E. A blinded investigation into the accuracy of reflexology charts. Complement Ther Med.
2000;8:166–72.
[8] Ferrer DE, Dios R. Reflexology. Rev Enfermagem. 2005;28:42–46.
[9] Shahdadi H, Hodki RM, Abadi AA, Sheikh A, Moghadasi A. The effect of slow stroke backmassageon fatiguein patients undergoing
hemodialysis: arandomized clinical trial. Int J Pharm Technol. 2016;8:16016–23.
[10] Mirzaee F, Kaviani M. The effect of reflexology on nolipar women anxiety. Hayat. 2010;16:65–71. [Persian]
[11] Lee YM, Sohng KY. The effects of foot reflexology on fatigue and insomnia in patients suffering from coal workers’ pneumoconiosis. Tae-
han Kanho Hakhoe Chi. 2005;35:1221–28.
[12] Esther M, Chin Pang W. The effects of slow-stroke back massage on anxiety and shoulder pain in elderly stroke patients. Complement
Therapies Nurs Midwifery. 2004;10:209–16.
[13] Quattrin R, Zanini A, Buchini S, Turello D, Annunziata M, Vidotti C, et al. Use of reflexology foot massage to reduce anxiety in hospital-
ized cancer patients in chemotherapy treatment: methodology and outcomes. J Nurs Manage. 2006;14:96–105.
[14] Song RH, Kim DH. The effects of foot reflexion massage on sleep disturbance, depression disorder, and the physiological index of the
elderly. Taehan Kanho Hakhoe Chi. 2006;36:15–24.
[15] Poole H, Glenn S, Murphy P. A randomized controlled study of reflexology for the management of chronic low back pain. Eur J Pain.
2007;11:878–87.
[16] Pourghaznein T, Ghafari F. The effect of sole reflexology on severity of fatigue in pregnant women. Hayat. 2006;12:5–12. [Persian]
[17] Brygge T, Heinig J, Poulsen L. Refloxology, bronchial asthma. Respir Med. 2001;95:173–79.
[18] Hughes C, Smyth S, Lowe-Strong A. Reflexology for the treatment of pain in people with multiple sclerosis: a double-blind randomized
sham-controlled clinical trial. Mult Scler J. 2009;15:1329–38.
[19] Holland B, Pokorny ME. Slow stroke back massage: its effect on patients in a rehabilitation setting. Rehabil Nurs J. 2001;26:182–86.
[20] Zakeri Moghaddam M, Shaban M, Kazemnezhad A, Tavassoli K. Effect of exercise utilizing the rate of respiratory on fatigue in patient
with chronic obstructive pulmonary disease. Hayat. 2006;3:17–25. [Persian]
[21] Ghafari S, Ahmadi F, Nabavi M. Effects of applying hydrotherapy on fatigue in multiple sclerosis patients Mazandaran. Sci Transl Med.
2008;66:71–81. [Persian]
[22] Schneider R. Fatigue among caregivers of chronic renalfailure patients: a principal components analysis. Nephrol Nursing J.
2003;30:629–44.
[23] Bonner A. Levels of fatigue in people with ESRD living in far north Queensland. J Clin Nurs. 2007;17:90–98.
[24] Shaer Moghadam SH, Shahdadi H, MohammadPourHodki R, Shamsizadeh M, Shrafi H. The effect of hand reflexology on fatigue in
patients undergoing hemodialysis. J Zabol Univ Med Sci Health Serv. 2016;8:1–10. [Persian]
Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd

[25] Mok E, Woo CP. The effects of slow-stroke back massage on anxiety and shoulder pain in elderly stroke patients. Complement Therapies
Nurs Midwifery. 2004;10:209–16.
[26] Braun Curtin R, Bultman DC, Thomas-Hawkins C. Hemaodialysis patient’s symptom experiences: effects on physical and mental func-
tioning. Nephrol Nursing J. 2002;29:562–74.
[27] Sd W, Fried LF, Arnold RM, Fine MJ, Levenson DJ, Peterson RA, et al. Prevalence, severity and importance of physical and emotional
symptoms in chronic hemodialysis. J Am Soc Nephrol. 2005;16:2487–94.
[28] Ey C, Hy L. The relationship of fatigue, self-efficacy, family support and sleep factor in hemodialysis patients. J Korean Acad Nurs.
2005;17:435–43.
[29] Kim HB, Song GR. Fatigue and related factors in Korean patients on hemodialysis. Taehan Kanho Hakhoe Chi. 2005;35:701–08.
[30] Liu HE. Fatigue and associated factors in hemodialysis patient in Taiwan. Res Nurs Health. 2006;29:40–50.
[31] Murtagh FE, Addington-Hall J, Higginson IJ. The prevalence of symptoms in end stage renal disease: a systematic review. Adv Chronic
Kidney Dis. 2007;14:82–99.
[32] Tsay SL, Rong JR, Lin PF. Acupoints massage in improving the quality of sleep and zzquality of life in patients with end-stage renal dis-
ease. J Adv Nursing. 2003;42:134–42.
[33] Cassileth BR, Vickers AJ. Massage therapy for symptom control: outcome study at a major cancer center. J Pain Symptom Manage.
2004;28:244–49.

Brought to you by | University of California - Santa Barbara

6 Authenticated
Download Date | 9/30/18 5:14 PM