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F E AT U R E S

Effects of Reflexology on Pain in Patients With Fibromyalgia ■ Esra Akin Korhan, PhD ■ Meltem Uyar, MD ■ Can Eyigör, MD ■ Gülendam Hakverdioğlu Yönt, PhD, RN ■ Leyla Khorshid, PhD, RN

The aim of this study was to investigate the effect of reflexology on pain intensity in patients with fibromyalgia, using an experimental repeated-measures design, and a convenience sample of 30 fibromyalgia inpatients. Thirty patients aged 18 to 70 years with fibromyalgia and hospitalized in the algology clinic were taken as a convenience sample. Patients received a total of 12 60-minute sessions of reflexology over a period of 6 consecutive weeks. Reflexology was carried out bilaterally on the hands and feet of patients at the reflex points relating to their pain at a suitable intensity and angle. Subjects had pain scores taken immediately before the intervention (0 minute), and at the 60th minute of the intervention. Data were collected over a 10-month period in 2012. The patients’ mean pain intensity scores were reduced by reflexology, and this decrease improved progressively in the first and sixth weeks of the intervention, indicating a cumulative dose effect. The results of this study implied that the inclusion of reflexology in the routine care of patients with fibromyalgia could provide nurses with an effective practice for reducing pain intensity in these patients. KEY WORDS: pain, pain score, patients, patients with fibromyalgia, reflexology Holist Nurs Pract 2016;30(6):351–359

INTRODUCTION

Fibromyalgia syndrome is a clinical syndrome characterized primarily by chronic widespread pain and diffuse musculoskeletal aching and soreness, accompanied by poor sleep, fatigue, cognitive dys- function, irritable bowel and bladder, headache, and a variety of somatic complaints and morning stiffness.1-5

The American College of Rheumatology criteria for the diagnosis of fibromyalgia include widespread mus- culoskeletal pain of more than 3 months’ duration and pain on palpation of more than 11 of the 18 standard

Author Affiliations: Faculty of Health Science, Department of Nursing, İzmir Katip Çelebi University, Çiğli, İzmir, Turkey (Dr Korhan); Faculty of Medicine, Algology Department, Ege University, Bornova, İzmir, Turkey (Drs Uyar and Eyigör); Faculty of Health Science, Department of Nursing, Şifa University, Bornova, İzmir, Turkey (Dr Yönt); and School of Nursing, Ege University, Bornova, İzmir Turkey (Dr Khorshid).

We thank all the people who so willingly participated in this study.

The Institution at which the work was performed: İzmir Ege University Education and Research Hospital, Algology Clinic, İzmir, Turkey.

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Correspondence: Esra Akin Korhan, PhD, Faculty of Health Science, Department of Nursing, İzmir Katip Çelebi University, Çiğli, İzmir, Turkey ([email protected]).

DOI: 10.1097/HNP.0000000000000178

tender points.6 The etiology of fibromyalgia is still unknown.7 Muscle abnormalities, sleep disturbances, and a biochemically unbalanced metabolism have all been considered as playing a part in fibromyalgia.3

Fibromyalgia tends to be more common among women than among men, with female prevalence ranging from 73% to 88%.8,9 Women are 10 times more likely to develop fibromyalgia than men, and the occurrence of the condition increases with age.3,10,11

In fibromyalgia, frequently observed symptoms are widespread chronic pain of the musculoskeletal system, tiredness and fatigue, waking up in the morning with a feeling of tiredness, restlessness, stiffness in the morning, a subjective feeling of bloating in the soft tissues, paresthesia, tremor, excessive perspiration, cold extremities, globus sensation, chronic headache (migraine), temporomandibular joint pain, dysmenorrhea, premenstrual syndrome, irritable colon syndrome, dysuria, functional respiratory system symptoms, functional cardiac symptoms, symptoms that change with the weather, symptoms that increase with stress and anxiety, Raynaud’s phenomenon, and anxiety symptoms.10,12 One of the symptoms most frequently experienced by patients with fibromyalgia is pain. Fibromyalgia is regarded as a chronic musculoskeletal

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pain disorder: burning, searing, tingling, shooting, stabbing, or sharp pain, or deep aching, typifies fibromyalgia; the pain is widespread, emanates from periarticular structures, and is characterized by distinct tenderness to palpation at a number of widely distributed “tender point” sites.13 For this reason, the standard of medical care has been focused chiefly on pain management and modulation of fatigue.7

Although the exact etiology of fibromyalgia is unknown, the existing recommendation for fibromyalgia is to use a multidisciplinary individualized approach that combines medications, relaxation techniques, biofeedback, activity pacing, sleep hygiene, cognitive behavioral therapy, graded exercise, physical and occupational therapy, and appropriate complementary modalities.14 The lack of any known cure for fibromyalgia along with a poor prognosis and ongoing chronic symptoms has led many patients to turn to complementary and alternative medicine (CAM) therapies in search of possible pain relief. Eisenberg et al performed a national survey of CAM use in the United States and found that a little over a third of Americans reported the use of at least one CAM therapy in the previous year. Many studies have documented even higher rates of CAM usage by patients with fibromyalgia, including a study showing that 50% of patients attending the Mayo Clinic’s fibromyalgia treatment program reported using some type of CAM therapy.15-17 An assessment of the use and satisfaction with alternative medicine practices by patients with fibromyalgia and a comparison of patients with fibromyalgia with other patients with rheumatology were made in a study in Canada. The findings indicated that 73 (91%) of patients with fibromyalgia identified alternative medicine use, compared with 140 (63%) of control patients. In reviews by Schneider et al4 and Kalichman,18 it was found that complementary and alternative techniques such as massage, reflexology, and acupuncture were the most frequently used in the management of symptoms in patients with fibromyalgia.

Few rigorous studies have demonstrated the effects of reflexology as an effective treatment for chronic symptoms. One study was encountered in the literature, which found that reflexology was effective for the symptoms experienced by patients with fibromyalgia,3 and this only dealt with its effect on pain levels.

The aim of this study was to investigate the effect of reflexology applied by the nurse on self-reported pain intensity in patients with fibromyalgia.

LITERATURE REVIEW

The PubMed/MEDLINE, Cochrane Library, and Science direct electronic databases were screened using the key words “fibromyalgia syndrome,” “chronic pain,” “alternative methods,” and “reflexology.”

REFLEXOLOGY AND PAIN

Reflexology is a reliable, noninvasive, integrated recovery and specific pressure technique that does not have side effects and requires the application of direct local pressure on reflex points on the hands, feet, and ears.19-22 Reflexology, which is an ancient healing art,6

a holistic noninvasive pressure19 and a touch therapy,23

is a system of massage based on the principles that there are reflex points on the feet, hands, and ears, which correspond to every part, organ, and gland of the body.6,19,22,24-26 All approaches to reflexology develop very specific maps of the feet, hands, or ears showing these connections.22 When a gentle pressure is applied to a particular zone of the feet, hands, or ears, it influences the corresponding zone in the body.26,27 Pressure applied to these specific areas assists in potentiating the normal functioning of the corresponding body part25 and activates the body’s inherent healing power.6 Releasing and activating the healing powers of the body and balancing the biological systems,6,25 reflexology causes extreme relaxation23,27 and produces a wonderful sense of well-being.19,23,27 It is also suggested that reflexology stimulates the release of endorphins, the body’s painkilling chemical.27 Reflexology facilitates homeostasis24 and relaxes the body, mind, and spirit19; it is effective in helping to diminish a variety of adverse symptoms such as stress, fatigue, pain, and tension23 and helps with anxiety and depression.6

REFLEXOLOGY

In reflexology, a variety of foot massage techniques are employed using the thumb and forefinger.28 One of them is palpation of the feet, which is used to gather information on the patient’s overall health. Areas of the feet that are sensitive, painful, or “gritty” are noted.22 The principle is that a reflexologist will break down the uric acid crystals to help the patient toward better health. Reflexology is different from foot massage in that it involves more superficial contact

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Effects of Reflexology on Pain in Patients With Fibromyalgia 353

and deeper pressure on certain parts of the foot, and resembles a caterpillar-like movement.28 Any congestion or problems in the body show up as sensitivities when pressure is applied. Changes in the skin are taken to indicate areas of energy stagnation in the corresponding zone. Denser areas suggest the need for deeper massage of those regions to decongest the energy.19,22 It has been claimed that by pressing the “reflex zones,” energy blocks or disturbances such as calcium, lactate, or uric acid crystals are reabsorbed and later eliminated—a process referred to as “detoxification.”28,29 Reflexology works via the nervous system with pressure applied to reflexes in the feet, which sends a signal to the peripheral nervous system and then enters the central nervous system where the brain can process the information. The brain relays messages to internal organs and glands to make adjustments such as getting more nutrients and oxygen into the cells.6 Several reflexology sessions will normally be suggested for maximum benefit.22

EFFECTS OF REFLEXOLOGY ON DIFFERENT DISORDERS

Researchers have examined the effectiveness of reflexology in improving the perceived health and well-being of patients with irritable bowel syndrome,7

in relieving migraine and tension headache,21 in improvement of sleep quality in patients with insomnia,30 in treating encopresis and constipation in children,24 in reducing anxiety in hospitalized patients with cancer in chemotherapy treatment,31 in decreasing anxiety in patients undergoing coronary artery bypass graft surgery,20 in evaluating the effect of reflexology on mood and symptom rating of patients with advanced cancer,32 in reduction in observed pain in nursing home residents,33 in decreasing pain intensity and anxiety in patients with metastatic cancer,33 in investigating the effect of foot reflexology on general fatigue, foot fatigue, mood, and blood glucose levels in non-insulin-dependent patients,34 and in a symptomatic treatment for breast cancer.34,35 In recent studies, reflexology has been described as an important treatment method in reducing anxiety, agitation, and pain, providing relaxation and comfort, and increasing sleep quality.7,36,37 In the only study examining the effects of reflexology on the symptoms of patients with fibromyalgia, it was found that reflexology helped to reduce these symptoms, that it reduced the intensity of pain experienced, and helped patients to relax.3

ALLAYING THE PAIN IN FIBROMYALGIA

In a systematic review and meta-analysis by Lauche et al,38 low-quality evidence was found for a short-term improvement of pain after Qigoing for fibromyalgia. In another review study by Terhorst et al,39 balneotherapy, mind-body, and acupuncture trials showed evidence of effectiveness interventions for fibromyalgia. In a third review study by Schneider et al4 aimed to perform a comprehensive review of the literature for the most commonly used treatment procedures in chiropractic for fibromyalgia syndrome, strong evidence was found to support aerobic exercise and cognitive behavioral therapy, and moderate evidence was found to support massage, muscle strength training, acupuncture, and spa therapy (balneotherapy).

METHODS

Ethical considerations

This study was approved by the Ethics Committee of the University, Izmir, Turkey. Permission to conduct the study was obtained from the Director of Doctors and Clinical Services. All the patients were informed regarding the procedures of the study, and informed consent was obtained from each of the participants.

Study design

An experimental repeated-measures design was used in this study to test the effects in question. The algology clinic of a university hospital in Izmir was utilized for the study. The algology clinic is interventional pain treatment modulation. The patients, who had been diagnosed with fibromyalgia, were all receiving the standard treatment for fibromyalgia, and moderate pain relief had been provided. On the day when the reflexology was given, no kind of analgesic was given before, during, or immediately after the reflexology.

The research hypotheses for the study were:

1. Reflexology sessions administered to patients with fibromyalgia reduce pain intensity scores between specified time points.

2. There are significant differences between 0 and the 60th minute in terms of mean visual analog scale (VAS) pain intensity scores reported by patients with fibromyalgia.

3. There are significant differences between mean VAS week 1 and Mean VAS week 6 in terms of mean

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354 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2016

VAS pain intensity scores reported by patients with fibromyalgia.

Patient selection criteria

Sample size was determined on the basis of repeated-measures analysis of variance (R_ANOVA) power analysis. Power analysis revealed that a sample size of 30 would achieve a power of 99% using an effect size 0.85 and an α coefficient of 0.05. The target population for the research was those patients who were hospitalized in the algology unit of the hospital. An MD who specializes in treating patients with fibromyalgia recruited eligible participants, men or women, who were diagnosed with fibromyalgia according to the American College of Rheumatology criteria. A convenience sample (n = 30) was taken from patients who met the study criteria and were hospitalized in the algology unit between January 1, 2012, and November 1, 2012. The sample consisted of 30 women who were all of Turkish nationality, were aged 18 to 70 years (mean = 43.30, standard deviation = 9.70) and had been diagnosed with fibromyalgia, and who had no psychiatric illnesses, no neurological illnesses, and no laterality problem; they had both feet and all toes intact and free from wounds; and they had not taken any sleep aid or sedative drug, had not been receiving any treatment by complementary or alternative methods.

The patients selected for the sample had not been given any nonpharmacological treatment or any integrative therapy before the reflexology was administered. Only pharmacological treatment was specified in the patients’ treatment protocols. The selection of patients was based on their declarations during interviews that they had not received any integrative therapy by their own choice.

Demographic data collected from the patients’ medical records comprised years since diagnosis of neuropathic pain, age, gender, education level, duration of pain, frequency of pain, and the intensity of pain generally experienced by patients.

Intervention

Each reflexology treatment was carried out in a private room at the algology clinic, affording privacy and a quiet space to work in. Before the initial treatment, an education of what reflexology was and what might be expected during the treatment was provided, and the subject also completed both outcome measures. The

subject was supported in a comfortable supine position for each treatment. Patients received a total of 12 60-minute sessions of reflexology over a period of 6 consecutive weeks.

Participants received precision reflexology involving a sequence of pressure massage, which allowed stimulation of the numerous specific reflex points on the feet associated with organs throughout the body. This method was based on that developed by Eunice Ingham,40,41 which is supported by the International Institute of Reflexology. Reflexology was applied to the hands and feet of patients bilaterally at a suitable angle and intensity in relevant areas relating to pain in the brain, cortex, hypothalamus, pituitary gland, subcortex and adrenal glands. The researcher, who had a certificate in reflexology, stimulated all reflex zones in both feet and hands using the thumb and finger technique resembling a “caterpillar”-like action.42 Patients’ pain scores were recorded separately using the VAS before the start of the reflexology treatment (0 minute) and immediately after the treatment was completed (60th minute) each week for a total of 6 weeks.

Instruments

Data collection included demographic data: age, gender, education level, duration of pain, the frequency of pain, and years of neuropathic pain diagnosis. The measures used in this study consisted of one standardized instrument, the VAS. The VAS is a simple and often-used method for evaluating variations in pain intensity43 and other subjective clinical phenomena. Subjects are instructed to indicate the intensity of the pain by marking a l00-mm line anchored with terms describing the extremes of pain intensity. Its usefulness has been validated by several investigators in the setting of chronic pain.44,45

Gonzalez et al46 reported that the reliability of the Spanish version of the VAS was 0.64 in Hispanic persons with chronic arthritis and that there was a strong correlation (0.72) with the visual numeric pain scale, supporting its construct validity. Daily pain was measured using the VAS at bedtime. Pain intensity was measured by using a vertical VAS from 0 to 10, with high numbers meaning greater pain intensity.

Data analysis

Power analysis was used to determine sample size. Using the VAS to distinguish results between the

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Effects of Reflexology on Pain in Patients With Fibromyalgia 355

applications with a power of 100%, and to achieve the difference between the periods evaluated with a power of 100%, it was determined that a sample size of 30 was sufficient for this study. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) for Windows (version 17.0). A 95% confidence interval (α = .05) was considered in all tests.

An R_ANOVA was used to examine mean VAS scores across the intervention period and comparisons between the 0 and the 60th minute within groups. The R_ANOVA was also used to examine mean VAS scores across the intervention period, measured at 6 weekly intervals within groups. For this reason, the Bonferroni test was used to examine the difference between the intervals within groups, and to examine the interaction between groups and times. The Bonferroni contrasts were carried out to compare the mean VAS scores measured at 3 time points, such as comparisons between mean VAS first week and mean VAS second week, mean VAS first week and mean VAS third week, mean VAS first week and mean VAS fourth week, mean VAS first week and mean VAS fifth week, and mean VAS first week and mean VAS sixth week, after obtaining a significant within-subject effect. The R_ANOVA was used to examine the effects of sociodemographic characteristics and the frequency and intensity of the pain generally experienced by the patients on the difference in the VAS score of pain occurring during the reflexology in the group.

RESULTS

Demographic characteristics

The study participants ranged in age from 18 to 70 years (mean, 43.30 years; standard deviation, 10.21 years). The sample consisted of 30 Turkish subjects, 30 female. Most were educated to primary school level (n = 10), 6 to secondary school level, and 14 to high school or university level. The number of years since patients had been diagnosed with fibromyalgia ranged from more than 1 year to more than 20 years. Mean time since diagnosis was 5.80 years (standard deviation, 7.64). All of the patients had experienced pain throughout the period since their diagnosis. It was determined that 70.0% of patients suffered from pain “always,” and 30.0% of them experienced pain “frequently.” Age and educational level had no effect on pain scores (P > .05). There were statistically significant differences in the baseline data of the frequency and intensity of pain generally

felt by the patients, and the patients’ pain scores (P < .05).

Effects of reflexology

The mean VAS scores of patients immediately before the reflexology session (0 minute) and immediately after it (60th minute) were found to be as follows: in the first week, 8.13 and 6.20; in the second week, 7.77 and 5.87; in the third week, 6.193 and 4.93; in the fourth week, 5.77 and 3.90; in the fifth week, 4.50 and 2.87; and in the sixth week, 3.30 and 3.30 respectively. When the mean VAS scores for 0 minute and the 60th minute are compared internally, it can be seen that the differ- ences are statistically significant (P < .05) (Figure 1).

The mean weekly VAS scores of patients were found to be 7.17 ± 1.75 for the first week (Figure 2), 6.82 ± 1.86 for the second week (Figure 3), 5.93 ± 1.72 for the third week (Figure 4), 4.83 ± 1.73 for the fourth week (Figure 5), 3.68 ± 1.42 for the fifth week (Figure 6), and 2.30 ± 1.22 for the sixth week (Figure 7). There was found to be a statistically significant difference between weeks in the mean VAS scores (P < .05).

An examination of the difference of the mean VAS score for each week from the other weeks shows that there was no statistically significant difference between the mean VAS scores of the first and second weeks (P > .05), but that there was a statistically significant difference between the values for weeks 3, 4, 5, and 6 (Table). Mean VAS scores for patients in the second week were not significantly different from

FIGURE 1. Mean VAS score of patients at the six weeks.

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356 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2016

FIGURE 2. Mean VAS score of patients at the first week.

those in the first week (P > .05), but the difference from the values for weeks 3, 4, 5, and 6 was significant (P < .05) (Table). The difference between patients’ mean VAS scores for the third week and the values for weeks 1, 2, 4, 5, and 6 was found to be statistically significant (P < .05) (Table). The difference between patients’ mean VAS scores for the fourth week and the values for weeks 1, 2, 3, 5, and 6 was found to be statistically significant (P < .05) (Table). The difference between patients’ mean VAS scores for the fifth week and the values for weeks 1, 2, 3, 4, and 6 was found to be statistically significant (P < .05) (Table). The difference between patients’ mean VAS scores for the sixth week and the values for

FIGURE 3. Mean VAS score of patients at the second week.

FIGURE 4. Mean VAS score of patients at the third week.

weeks 1, 2, 3, 4, and 5 was found to be statistically significant (P < .05) (Table).

DISCUSSION

Fibromyalgia is difficult to treat by clinical methods, and nonpharmacological treatment options can help in this regard. Reflexology has been recognized and specifically used as a therapeutic intervention since the mid-20th century, but it has existed in various forms in most cultures for many centuries. In recent years, the use of reflexology as an intervention has increased and this, to some extent, may reflect the growing interest in complementary therapies.

FIGURE 5. Mean VAS score of patients at the fourth week.

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Effects of Reflexology on Pain in Patients With Fibromyalgia 357

FIGURE 6. Mean VAS score of patients at the fifth week.

Reflexology was used in this study as a nonpharmacological nursing intervention to facilitate the relief of pain. It reduced pain among patients with fibromyalgia, and pain scores decreased over time for the subjects in the reflexology group. These findings were supportive of the hypothesis that reflexology has a significant effect in reducing VAS pain scores in patients with fibromyalgia. Findings from this study on pain scores were congruent with other studies of decreased pain scores in patients with different pain in response to reflexology intervention.21,47,48 In a study by Launsö et al,21 patients described less pain after reflexology treatment for headache. Stephenson et al47

also provided evidence that foot reflexology was effective in reducing pain and anxiety, and it could be integrated into standard care. In a study of patients with metastatic cancer by Stephenson et al,49 it was shown that pain scores decreased during the reflexology intervention. In a study by Wallace (2003, cited in Stephenson et al49), foot reflexology was

FIGURE 7. Mean VAS score of patients at the sixth week.

found to have an immediate positive effect for patients with metastatic cancer who reported pain. In a study by Park et al,50 a significant decrease in pain scores was found during reflexology sessions in patients with breast cancer. In a study by Khan et al,51 reflexology was associated with a reduction in foot pain as described by patients with rheumatoid arthritis. In a study by Quinn et al,52 patients described less pain after reflexology treatment for low back pain. Brown and Lido53 provided evidence that reflexology was effective in reducing pain and that there was an improvement in the perception of the presence and the intensity of phantom limb pain, with a corresponding improvement in the duration of the pain and the person’s lifestyle. In a study by Samuel and Ebenezer,48 a significant decrease in pain scores and the amount of analgesia were found during reflexology sessions in acute pain.

Systematic reviews on reflexology indicate that it is effective in reducing pain scores. Despite the results of various studies examining the effect of reflexology on

TABLE. Significance of the Difference Between Mean VAS Scores of Patients Measured at Different Times

Measured at Different Times

First Week

Second Week

Third Week

Fourth Week

Fifth Week

Sixth Week

First week a a a a

Second week a a a a

Third week a a a a a a

Fourth week a a a a a a

Fifth week a a a a a a

Sixth week a a a a a a

aStatistically significant (P = .05).

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358 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2016

pain with different sample groups, there has been only one study examining the effect of reflexology on fibromyalgia. In a study to examine the effect of reflexology on the symptoms of patients with fibromyalgia, Gunnarsdottir and Peden-McAlpine3

gave patients a total of 10 sessions of reflexology of 45 minutes each. Their results showed that reflexology had a reducing effect on symptoms of fibromyalgia, that it reduced pain experienced for example in the head, chest, and arms, and that it generally isolated pain and reduced its intensity.

Our results indicated that reflexology had decreased pain scores. The decreasing trend continued in the first and sixth weeks of the intervention, implying a cumulative dose effect. This suggests that reflexology should be used over periods of at least 6 weeks. Age, gender, and educational level had no effect on pain scores.3 Also, the frequency and intensity of pain generally experienced by the patient had an effect on pain scores. This result indicates that reflexology, which has a significant reducing effect on pain, can be more effective as the frequency and intensity of pain in the patient are reduced, and considerably reduces the pain perceived. Nurses are in a primary position to conduct research on reflexology, in that their holistic background is in tune with the philosophies behind reflexology. Before reflexology is used within hospital settings to benefit patients, more empirical research evidence is needed to support its use.

CONCLUSION

Pain scores were reduced significantly after reflexology was completed, and findings supported the benefits of reflexology for patients with fibromyalgia. Reflexology has an influence that can be used as a therapeutic tool for lowering pain scores in patients with fibromyalgia. It is a safe intervention that is not detrimental to patients, and has the advantage of managing pain in patients with fibromyalgia without risking unwanted side effects.

Reflexology is a noninvasive, inexpensive, and non-time-consuming nursing intervention. It is recommended that studies be conducted to explore the optimal time, duration, or number of reflexology sessions to be used when implementing reflexology. Nurses who work in algology clinics may apply therapy as a nonpharmacological intervention to decrease pain scores in patients with fibromyalgia.

Relevance to clinical practice

� Reflexology should be considered as a first-line therapy to allay pain in patients with fibromyalgia pain.

� Nurses should include reflexology in the routine care of patients with fibromyalgia pain.

� Further research is needed to investigate the effects of the duration of the application and the areas to which reflexology is applied (ear or hand or foot) on patients with fibromyalgia pain.

Limitations

This study reflects an encouraging insight into the future of reflexology, but further studies should be made with larger samples to verify the results of our study. The fact that the research nurse was not blinded as to the allocation of each group is another limitation of the study. Under limitations consider addressing that the effects of the intervention were not measured over time; as in 6 months postintervention.

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