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Original Article

The Effects of
Aromatherapy Massage
and Reflexology on Pain
and Fatigue in Patients
with Rheumatoid
Arthritis: A Randomized
Controlled Trial
--- Zehra Gok Metin, Research Assistant, PhD, RN
and Leyla Ozdemir, Associate Professor, PhD, RN

- ABSTRACT:
Nonpharmacologic interventions for symptom management in patients
with rheumatoid arthritis are underinvestigated. Limited data suggest
that aromatherapy massage and reflexology may help to reduce pain
and fatigue in patients with rheumatoid arthritis. The aim of this study
was to examine and compare the effects of aromatherapy massage and
reflexology on pain and fatigue in patients with rheumatoid arthritis.
The study sample was randomly assigned to either an aromatherapy
massage (n 17), reflexology (n 17) or the control group (n 17).
From the Department of Internal
Aromatherapy massage was applied to both knees of subjects in the first
Medicine Nursing, Hacettepe intervention group for 30 minutes. Reflexology was administered to
University Faculty of Nursing, both feet of subjects in the second intervention group for 40 minutes
Ankara, Turkey.
during weekly home visits. Control group subjects received no inter-
Address correspondence to Zehra Gok vention. Fifty-one subjects with rheumatoid arthritis were recruited
Metin, PhD, RN, Research Assistant, from a university hospital rheumatology clinic in Turkey between July
Department of Internal Medicine
2014 and January 2015 for this randomized controlled trial. Data were
Nursing, Hacettepe University Faculty
of Nursing, Ankara 06100, Turkey. collected by personal information form, DAS28 index, Visual Analog
E-mail: zehragok85@hotmail.com Scale and Fatigue Severity Scale. Pain and fatigue scores were measured
at baseline and within an hour after each intervention for 6 weeks. Pain
Received August 31, 2015;
Revised January 29, 2016; and fatigue scores significantly decreased in the aromatherapy massage
Accepted January 30, 2016. and reflexology groups compared with the control group (p < .05). The
reflexology intervention started to decrease mean pain and fatigue
Funding: None.
scores earlier than aromatherapy massage (week 1 vs week 2 for pain,
Conflicts of interest: None.
week 1 vs week 4 for fatigue) (p < .05). Aromatherapy massage and
1524-9042/$36.00 reflexology are simple and effective nonpharmacologic nursing inter-
2016 by the American Society for
ventions that can be used to help manage pain and fatigue in patients
Pain Management Nursing
http://dx.doi.org/10.1016/ with rheumatoid arthritis.
j.pmn.2016.01.004 2016 by the American Society for Pain Management Nursing

Pain Management Nursing, Vol -, No - (--), 2016: pp 1-10


2 Gok Metin and Ozdemir

BACKGROUND (Brownfield, 1998; Ovayolu & Ovayolu, 2013). In a


quasi-experimental study, Kim et al. (2005) found
Pain and fatigue related to rheumatoid arthritis (RA) that aromatherapy massage significantly decreased
often decrease patients independence and may limit pain scores for patients with RA. In another quasi-
activities of daily living, which can negatively impact experimental study, Han et al. (2010) found that aroma-
patients quality of life (Edwards, Bingham, Bathon, therapy massage reduced pain scores and painful
& Haythornthwaite, 2006; Hewlett, Nicklin, & inflamed joints in patients with RA.
Treharne, 2008; Pollard, Choy, Gonzalez, Khoshaba, Reflexology is another complementary therapy
& Scott, 2006). Despite the high prevalence of RA- modality with potential beneficial effects in RA. Reflex-
related pain and fatigue, there are no curative treat- ology uses specific hand and finger techniques to apply
ments (Cornell, 2007). Conventional treatments for pressure to individual body parts and organs at specific
RA include pharmacologic treatments such as nonste- reflex points on the hands and feet to stimulate endo-
roidal anti-inflammatory drugs (NSAIDs), corticoste- crine glands (Wang et al., 2008). Reflexology has
roids, disease-modifying antirheumatic drugs been found to decrease migraine, neck and arm, and
(DMARD), and biologic drugs. However, these treat- low back and muscle-related pain and to improve mus-
ments have common and harmful side effects such as cle strength and tone (Gunnarsdottir & Peden-
liver and kidney toxicity, nausea, vomiting, loss of McAlpine, 2010; Poole, Glenn, & Murphy, 2007;
appetite, anemia, and ocular or systemic infections Quinn, Hughes, & Baxter, 2008; Siev-Ner, Gamus,
(Demirel & Kirnap, 2010). Additionally, these treat- Lerner-Geva, & Achiron, 2003). A case study reported
ments do not lead to a complete cure of the disease that reflexology significantly decreased pain scores
or its symptoms. after six 1-hour reflexology session (Khan, Otter, &
Nonpharmacologic interventions have also been Springett, 2006). Another study found that 45-minute
employed to manage symptoms and improve func- reflexology interventions over 6 weeks significantly
tional status (Kohara et al., 2004; O zdemir, Ovayolu, & lessened fatigue in RA patients (Khan, Otter, &
Ovayolu, 2013; Wang, Tsai, Lee, Chang, & Yang, 2008). Springett, 2006; Otter et al., 2010).
Nonpharmacologic interventions include physical ther- However, few of the previously mentioned studies
apy and rehabilitation; exercises; nutrition; peripheral tested the effects of aromatherapy massage and reflex-
techniques such as aromatherapy, massage, and refle- ology on RA-related pain and fatigue. The authors
xology; cognitive behavioral therapies; and acupun- could find no research comparing these modalities.
cture (Cramp et al., 2013; Hewlett et al., 2011; Wang The aim of this randomized controlled trial was to
et al., 2008). compare the effects of aromatherapy massage and
Aromatherapy is one of the complementary ther- reflexology on pain and fatigue in patients with RA.
apy modalities widely used around the world to We hypothesized that aromatherapy massage and
manage chronic disease symptoms (Buckle, 1999; reflexology interventions would decrease pain and fa-
Ernst, 2004; Kim, Nam, & Paik, 2005; Steflitsch & tigue scores in subjects with RA.
Steflitsch, 2008). Aromatherapy is defined as the use
of essential oils extracted from plants to produce
physiologic or pharmacologic effects through the METHODS
sense of smell or absorption through the skin
(Steflitsch & Steflitsch, 2008). Essential oils have Ethical Considerations
been used for their antiseptic, antibacterial, analgesic, This study was approved by the Ethical Commission of
anti-inflammatory, antispasmolytic, antitoxic, immune- Turgut Ozal University, Ankara. The aim and the
stimulatory, and relaxing effects for management of the method of the study were explained to the subjects,
symptoms of cancer, respiratory diseases, migraine, hy- and informed consent was obtained from each of the
pertension, arthritis, and muscle-related pain (Basaran, subjects. Study subjects were informed that if they
2009; Steflitsch & Steflitsch, 2008; Yip & Tam, 2008). did not want to continue, they could withdraw from
Essential oils have also been used with massage the study without stating a reason.
because of their quick absorption into the skin. Aroma-
therapy and massage have been used in juvenile RA, fi- Design and Sample
bromyalgia, and chronic fatigue syndrome to relieve This was a randomized controlled trial comparing the
pain, fatigue, morning stiffness, and anxiety (Ernst, effects of aromatherapy massage, reflexology, and no
2004; Field, Diego, Hernandez-Reif, & Shea, 2007; intervention on pain and fatigue levels in subjects
Field et al., 1997; Kim et al., 2005). Increased with RA. Data were collected between July 2014 and
physical and mental well-being have also been noted January 2015. A convenience sample of 54 adults
Aromatherapy Massage and Reflexology in Rheumatoid Arthritis 3

with RA was recruited from a rheumatology clinic of a study. In addition, those who were pregnant, anemic,
university hospital located in a large city in Turkey. All or who had a Disease Activity Score (DAS28) > 5.1
subjects suffered from pain and fatigue symptoms. To were also excluded from the study.
be included in the study, subjects must have been The software package G-power (Faul, Erdfelder,
18 years or older, diagnosed with RA for at least Buchner, & Lang, 2009) was used to conduct an apriori
1 year, had a Visual Analog Scale (VAS) score of $4 power analysis to calculate the number of subjects
points and a Fatigue Severity Scale (FSS) score of $4 required. Fifty-one subjects (17 subjects in each study
points, not currently using biological drug therapy, group) were required to detect an effect size of 0.3
and not currently receiving physiotherapy or using at 80% power. The alpha level used to define signifi-
any complementary therapy modalities. Subjects with cance was 0.05.
knee and foot wounds or surgery, cancer, osteoar- Figure 1 presents a flow diagram of subject selec-
thritis, essential oil allergies, and blood coagulation dis- tion and progress through the study. Fifty-four subjects
orders such as hemophilia were excluded from the met the inclusion criteria and provided consent. Subjects

Assessed for eligibility (n = 90)

Excluded (n = 36)
Not meeting inclusion
criteria (n = 30)
Declined to participate (n = 6)
Other reasons (n = 0)

Randomized (n = 54)

Allocation

Allocated to aromatherapy Allocated to reflexology (n = 18) Allocated to control (n = 17)


massage (n = 19)

Follow-Up

Lost to follow-up (n = 2) Lost to follow-up (n = 1) Lost to follow-up (n = 0)


1 Biological therapy 1 Moved to
1 Withdrew

Analysis

Analysed (n = 17) Analysed (n = 17) Analysed (n = 17)


Excluded from analysis (n = 0) Excluded from analysis (n = 0) Excluded from analysis (n =0)

FIGURE 1. - Flow diagram of subject progress through the phases of randomized trial.
4 Gok Metin and Ozdemir

TABLE 1.
Active Substances in Essential Oils and Their Effects
Essential Oil Active Substances (%) Effects on the Body

Juniperus officinalis a-Pinene (38.99) Analgesic


Sabinen (10.75) Antiviral
Mycren (13.39) Antioxidant
Limonene b-Phelleandrene (4.05) Antitoxic
Terpinen-4-ol (3.92) Sedative
d-Germacren (3.66)
Lavendula augustifolia c-b-ocimen limonen (3.69) Anti-inflammatory
Linalool (30.51) Analgesic
Linalyacetat (36.62) Antiseptic
Lavandula asetat (2.90) Sedative
t-b-ocimen (3.03) Circulation-stimulating
1,8 Cineol (0.55) Cell regenerating
Terpinen-4-ol (2.91)
Cananga odarata Linalool methylbenzoat (7.54) Antiseptic
Geranylacetate (7.75) Muscle relaxant
b-Caryophellen (11.16) Cell regenerating
Germacren-D (19.16) Anti-neuralgic
t-t-a-Farnesen (10.45) Antidepressant
d-Cadinen (3.37) Analgesic
Benzyl benzoate (6.52)
Rosmarinus officinalis a-Pinen (11.32) Antiviral
Limonene (2.51) Antibacterial
1,8 cineol (47.18) Anti-inflammatory
Linalool (0.93) Antioxidant
Kampher (11.46)
b-Caryophylen (2.86)

were stratified by disease duration, VAS score, FSS score, examinations and obtained demographic information,
DAS28 score, and type of RA treatment (DMARD or VAS, and FSS scores. All study individuals were then in-
DMARD plus steroids). Next, subjects were assigned to structed on how to rate their own VAS and FSS scores.
either the control group (n 17) or experimentalgroups For the control group, the PI made weekly calls to
that received aromatherapy massage (n 19) or reflex- obtain subjects VAS and FSS scores during the study
ology (n 18) interventions by using a random number period. For the individuals in the experimental groups,
table. During the intervention, three subjects (two from the PI made weekly home visits to deliver aroma-
the aromatherapy massage group and one in the reflex- therapy massage or reflexology interventions, after
ology group) were lost to attrition. which subjects were asked to complete the VAS and
FSS scales within an hour following each intervention.
Data Collection Instruments. DAS28 has four components measuring
Baseline data were obtained by face-to-face interviews tender-joint count, swollen-joint count, erythrocyte
with the subjects in the rheumatology clinic. In these sedimentation rate (ESR), and self-reported general
interviews demographic information as well as health. The 28 tender joint count (28TJC) and 28
DAS28, VAS, and FSS scores were obtained. Demo- swollen joint count (28SJC) both have a range of 0
graphic information included the subjects age, sex, 28. ESR range is 0150; the general health (GH) range
educational level, employment, smoking status, fre- is 0100. DAS28 is a continuous index with a range of
quency of exercise, health history data, treatment 09.4. The level of RA disease activity is classified as
period, treatment type, and use of complementary low (DAS28 # 3.2), moderate (DAS28 3.2 to # 5.1),
therapies (Diracoglu, 2007; Edwards et al., 2006; or high (DAS28 > 5.1). A DAS28 < 2.6 corresponds
Helmick et al., 2008). to remission status according to the American Rheuma-
All study subjects physical examinations and tism Association (ARA) criteria (Fransen, Stucki, & van
DAS28 score calculations were carried out by the Riel, 2003).
same rheumatologist. The principal investigator (PI) in- VAS for pain consists of a 10-cm horizontal scale
terviewed subjects face-to-face after their physical with the descriptor of no pain on the left and worst
Aromatherapy Massage and Reflexology in Rheumatoid Arthritis 5

TABLE 2.
Disease and Baseline Characteristics of Subjects (N 51)
Aromatherapy Reflexology Control

Characteristic n % n % n % c2 , p

Time since RA diagnosis (years) (10.7 T 7.8)


<10 7 41.1 12 70.6 9 52.9
$10 10 58.9 5 29.4 8 47.1 0.000, 1.000
Pain score (5.9 T 1.88)
46 11 64.7 11 64.7 12 70.6 0.176, .916
710 6 35.3 6 35.3 5 29.4
Fatigue score (5.60 T 0.85)
4-5.6 7 41.1 8 52.9 11 64.7 2.040, .361
5.7-7 10 58.9 9 47.1 6 35.3
DAS28 score (2.82 T 0.88)
<2.6 8 47.1 5 29.4 7 41.2 1.152, .562
>2.7 9 52.9 12 70.6 10 58.8
RA treatment protocol
DMARD 8 47.1 8 47.1 8 47.1 0.000, 1.000
DMARD Steroid 9 52.9 9 52.9 9 52.9

possible pain on the right (Eti Aslan, 2002; Scott & asked not to take analgesic drugs on the days of the
Huskisson, 1979). Subjects were asked to place a intervention.
mark on the line at a point that corresponded to the Aromatherapy Massage. The aromatherapy mas-
level of pain intensity they were currently feeling. To sage essential oil was a 5% mixture consisting of Lavan-
provide group homogeneity, subjects were divided dula augustifolia, Juniperus communis, Cananga
into two subgroups: mild to moderate (46) and odorata, and Rosmarinus officinalis in the ratio
severe (710) pain intensity. 3:3:2:2 in 100 mL of coconut carrier oil (Buckle, 1999;
The Fatigue Severity Scale (FSS) is a nine-item Chang, 2008) (Table 1). The choice of essential oils
scale that measures the effect of fatigue on daily living was determined in consultation with the Department
using statements, such as I am easily fatigued. of Pharmacology, based on a review of the literature
Possible responses range from one (completely (Faixov & Faix, 2008; Kang & Kim, 2008; Tumen &
disagree) to seven (completely agree) (Schwartz, Hafzoglu, 2003).
Jandorf, & Krupp, 1993). Subjects with a mean score Before beginning the aromatherapy massage, sub-
of four or more were identified as suffering from signif- jects were placed in a supine position. The aroma-
icant fatigue. The Turkish FSS scale has a Cronbachs therapy oils were applied topically to both knees.
alpha reliability coefficient of 0.85 and internal consis- The PI remained seated on the same side as the inter-
tency of 0.94 (Gencay-Can & Can, 2012). vention knee. The first part of the massage was initi-
ated with superficial effleurage from the foot
Interventions superiorly, including the ankle and knee joint area,
Consistency of the aromatherapy massage and reflex- for 3 minutes before applying essential oils. In the sec-
ology interventions was ensured by using one individ- ond part of the massage, the knee area was divided into
ual (the PI) to collect data and administer treatments four equal quadrants (with an imaginary plus sign pass-
using the same intervention technique. Aromatherapy ing midpatella). Five drops of the essential oil blend
massage and reflexology were administrated to sub- were applied to each quadrant (total 20 drops) with
jects by the PI, a certified aromatherapy massage, both hands and with circular movements on the
reflexology practitioner, and registered nurse. The con- knee for a total of 6 minutes. The third part of the mas-
trol group did not receive any sham interventions and sage technique was an additional 6 minutes of massage
usual care was continued. Aromatherapy massage and with five drops of essential oil blend for each quadrant
reflexology were performed during home visits in a (total 20 drops) of the right knee. After completing the
quiet room and at a convenient time for subjects. All 15-minute aromatherapy massage session for the right
study subjects continued to follow their routine RA knee, the massage was repeated on the left knee. The
treatments during the study. However, subjects were total duration of aromatherapy massage was
6 Gok Metin and Ozdemir

TABLE 3.
Demographic Characteristics of Subjects (N 51)
Aromatherapy Reflexology Control
Characteristic n % n % n %
Age (years) (mean 54.4 T 1.2)
1860 11 64.7 11 64.7 11 64.7
$61 6 35.3 6 35.3 6 35.3
Sex
Female 15 88.2 15 88.2 15 88.2
Male 2 11.8 2 11.8 2 11.8
Educational level
Primary school 10 58.9 10 58.8 11 64.7
High school 3 17.6 2 11.8 2 11.8
University 4 23.5 5 29.4 4 23.5
Employment
Employed 3 17.6 4 23.5 2 11.8
Retired 4 23.5 3 17.6 3 17.6
Unemployed 10 58.9 10 58.9 12 70.6
Smoking
Active 4 23.6 4 23.6 2 11.8
Never 10 58.8 9 52.8 9 52.9
Past 3 17.6 4 23.6 6 35.3
Exercise
3 times/week 3 17.6 0 0.0 2 11.8
<2 times/week 2 11.8 8 47.1 3 17.5
Irregular 8 47.1 5 29.4 8 47.2
No exercise 4 23.5 4 23.5 4 23.5
Comorbidity
Hypertension 8 53.3 6 40.0 4 26.7
Coronary artery disease 2 13.3 6 40.0 2 13.3
Diabetes mellitus 4 26.7 1 6.7 2 13.3
Hyperlipidemia 2 13.3 2 13.3 2 13.3
Complementary therapy
Experienced 8 47.1 5 29.4 6 35.3
Nonexperienced 9 52.9 12 70.6 11 64.7
Complementary therapy type
Spa/hot spring 5 62.5 4 80.0 5 83.3
Massage 0 0.0 0 0.0 1 16.7
Herbal therapy 3 37.5 0 0.0 0 0.0
Cupping 0 0.0 1 20.0 0 0.0

30 minutes. Aromatherapy massage was provided reflexology techniques. After completion of the right
three times each week for a 6-week period. foot, the same steps were repeated for the left foot.
Reflexology. Before the intervention, subjects were Reflexology was applied for 20 minutes on each foot,
placed in a supine position. During reflexology, the for a total of 40 minutes. Treatment was continued
PI sat on a chair facing the subjects feet, with the once weekly for a 6-week period.
feet at the PIs chest level. Relaxation techniques
were administered first to the right foot for 5 minutes. Data Analysis
After relaxation, all reflex points and the region associ- Data analyses were conducted using SPSS version 22.00
ated with the pituitary gland on the right foot were (SPSS, Inc, Chicago, IL, USA). A p value of <.05 was
stimulated with thumb pressing, finger pressing, rub- considered significant. Parametric data, such as subjects
bing, stroking, and squeezing for 3 minutes. Subse- pain and fatigue scores, were compared with ANOVA
quently, 12 minutes were spent stimulating the test. Nonparametric data, such as sex, educational level,
specific areas of the foot associated with the head, and exercise status were compared with frequency and
neck, shoulders, pineal, pituitary gland, solar plexus, Chi-square comparisons. Tukeys HSD post-hoc test
spinal column, knees, and spleen using the same was performed for defining the differences.
Aromatherapy Massage and Reflexology in Rheumatoid Arthritis 7

TABLE 4.
Comparison of Mean Pain Scores in Intervention and Control Groups (N 51)
*Difference
Measurement Time Patient Group N VAS X SD F p (Tukeys Test)

Baseline Aromatherapy 17 6.00 T 1.96 0.500 .610


Reflexology 17 6.35 T 2.17 -
Control 17 5.70 T 1.44

First week Aromatherapy 17 3.88 T 1.57 5.216 .009


Reflexology 17 2.38 T 2.02 2-3
Control 17 4.53 T 2.29

Second week Aromatherapy 17 3.00 T 1.73 7.573 .001


Reflexology 17 2.03 T 1.78 3-1,2
Control 17 5.00 T 3.04

Third week Aromatherapy 17 2.65 T 1.45 6.435 .003


Reflexology 17 2.00 T 1.73 3-1,2
Control 17 4.29 T 2.44

Fourth week Aromatherapy 17 2.18 T 1.81 8.305 .001


Reflexology 17 2.18 T 1.77 3-1,2
Control 17 4.56 T 2.27

Fifth week Aromatherapy 17 2.24 T 1.34 12.968 .001


Reflexology 17 1.53 T 1.46 3-1,2
Control 17 4.59 T 2.47

Sixth week Aromatherapy 17 1.59 T 1.17 22.652 .001


Reflexology 17 0.56 T 1.14 3-1,2
Control 17 4.29 T 2.38
*1 aromatherapy, 2 reflexology, 3 control.

RESULTS somewhat by group. The aromatherapy massage group


showed hypertension and diabetes mellitus as the most
Subjects Demographic and Disease common comorbidities, whereas the reflexology
Characteristics group showed hypertension and coronary artery dis-
Disease and baseline scores for the three groups are ease as more common. In the control group, hyperten-
shown in Table 2. The mean duration of diagnosis was sion was the most common comorbidity. Hypertension
10.7 T 7.8 years. The mean score for pain was 5.9 T was the most common comorbidity for all three study
1.88 years; mean score for fatigue was 5.6 T 0.85 years; groups. Although women were more likely than men
and mean score for DAS28 was 2.82 T 0.88. Regarding to have used complementary therapies, more than
treatments, all subjects were taking either DMARD or half of all subjects had never used any complementary
DMARD plus steroids. There were no significant differ- therapy. Of those who did use complementary therapy,
ences in RA characteristics or in the baseline parame- the most commonly used was spa/hot spring.
ters among the three groups (p > .05).
As shown in Table 3, subjects mean age was
54.4 T 1.2 years (range 2189 years). The great major- Intervention Effects
ity of the subjects were female (88.2%), with only 2 At the end of the monitoring period, the analysis
men in each study group. The preponderance of sub- showed a statistically significant decrease in VAS and
jects in all groups was unemployed (mean: 62.8%). FSS scores among the intervention groups compared
More than half of the all subjects had never smoked. with the control group (p < .05). Specifically, aroma-
An average of 41.2% of subjects did not exercise regu- therapy massage significantly decreased pain scores
larly, and almost 24% of subjects in each study group beginning the second week of the study. Reflexology
stated they never exercise. Comorbidities varied findings showed significantly decreased pain scores
8 Gok Metin and Ozdemir

TABLE 5.
Comparison of Mean Fatigue Scores in Intervention and Control Groups (N 51)
*Difference
Measurement Time Patient Group n FSS X SD F p (Tukeys Test)

Baseline Aromatherapy 17 5.86 T 0.71 1.449 .245 -


Reflexology 17 5.58 T 0.98
Control 17 5.37 T 0.82

First week Aromatherapy 17 4.75 T 0.76 4.296 .019 2-3


Reflexology 17 4.24 T 1.41
Control 17 5.30 T 0.85

Second week Aromatherapy 17 4.48 T 0.85 11.477 .001 2-1,3


Reflexology 17 3.26 T 1.45
Control 17 5.11 T 1.03

Third week Aromatherapy 17 4.08 T 1.08 8.828 .001 2-3


Reflexology 17 3.17 T 1.64
Control 17 4.97 T 0.88

Fourth week Aromatherapy 17 3.49 T 1.18 7.745 .001 3-1,2


Reflexology 17 2.82 T 1.75
Control 17 4.82 T 1.51

Fifth week Aromatherapy 17 3.48 T 1.12 11.078 .001 3-1,2


Reflexology 17 2.54 T 1.51
Control 17 4.64 T 1.24

Sixth week Aromatherapy 17 2.94 T 1.13 13.873 .001 3-1,2


Reflexology 17 1.88 T 1.18
Control 17 4.41 T 1.79
*1 aromatherapy, 2 reflexology, 3 control.

beginning the first week of the study (Table 4). Like- addition, reflexology appears to have a greater effect
wise, aromatherapy massage significantly reduced fa- than aromatherapy massage for reducing pain and fa-
tigue scores beginning the fourth week of the study. tigue scores in RA subjects.
Reflexology reduced fatigue scores beginning the first There was a significant reduction in the interven-
week of the study (Table 5). tion groups mean pain scores compared with the con-
The effects of the reflexology intervention were trol group throughout the intervention period,
earlier than for aromatherapy massage. In addition, beginning the first week for reflexology and the sec-
the pain scores were significantly lower each week ond week for aromatherapy massage. Similar to current
(except for week 4) for subjects who received the study results, aromatherapy massage administered to
reflexology intervention compared with subjects RA subjects for two consecutive evenings reduced
who received aromatherapy massage. Similar findings pain in a randomized controlled study (Brownfield,
were seen with fatigue scores. The fatigue scores 1998). In a quasi-experimental study, aromatherapy
were significantly lower each week for subjects who massage significantly decreased pain scores of RA sub-
received the reflexology intervention compared jects (Kim et al., 2005). Similarly, a quasi-experimental
with subjects who received aromatherapy massage study found that aromatherapy massage administered
(Tables 4 and 5). for 4 weeks reduced the number of tender and swollen
joints and pain scores in subjects with RA (Han et al.,
2010). Regarding reflexology, a case report using
DISCUSSION
reflexology for subjects with RA noted a decrease in
This study demonstrated that aromatherapy massage pain after the first session (Khan et al., 2006).
and reflexology were superior to a no- intervention In the current study, pain reduction in aroma-
control in reducing pain and fatigue scores. In therapy massage started later compared with
Aromatherapy Massage and Reflexology in Rheumatoid Arthritis 9

reflexology. This delayed effect may be due to essential CONCLUSIONS AND IMPLICATIONS
oils slow absorption by inflamed joints or differential FOR NURSING
response times among individuals to aromatherapy
massage. Reflexologys rapid impact can be attributed This study is intended to demonstrate the effectiveness
to its effects on nerves and joints, and stimulation of of aromatherapy massage and reflexology as pain and
the entire body immediately after intervention (Khan fatigue relief in a real-world setting such as a rheuma-
et al., 2006; Taha & Ali, 2011). tology clinic, and to justify their introduction in the
According to the results of this study, reflexology field of rheumatology.
is more effective than aromatherapy massage at In this study, aromatherapy massage and reflex-
reducing fatigue scores from the beginning of the inter- ology significantly decreased pain and fatigue symp-
vention. Nonetheless, aromatherapy massage also toms in subjects with RA in the short term. Thus,
decreased fatigue scores, starting the fourth week of the study confirms that aromatherapy massage and
the study. This result confirms previous work and reflexology can be applied as nonpharmacologic
may be interpreted as indicating that reflexology has methods for managing pain and fatigue in subjects
a quick effect on the body (Otter et al., 2010). Also, with RA. Based on the study results, aromatherapy
reflexology decreased pain scores starting the first massage and reflexology may be beneficial for RA sub-
week, and this led to relief of fatigue associated with jects. Moreover, these complementary treatments are
pain. useful for nurses who can apply aromatherapy mas-
sage and reflexology as a component of care for
Limitations symptom management in RA subjects. However, prac-
This study had some limitations. First, the PI collected titioner training and experience with aromatherapy
the data for both the control and experimental groups massage and reflexology are critical to achieving suc-
and administered all the interventions. This could be a cessful results.
potential bias. Another limitation was the homoge- The authors suggest that future research should
neous nature of the sample, which makes findings diffi- explore aromatherapy massage and reflexology for
cult to generalize to all subjects with RA. Third, this other RA symptoms such as joint immobility, sleep
study protocol occurred over 6 weeks with no follow- disturbance, and depression to provide more compre-
up, so the long-term effects are unknown. Therefore, hensive care for subjects with RA.
a study identifying the long-term effects would be
better able to describe the full impact of the
interventions. Finally, the effects of aromatherapy Acknowledgments
massage and reflexology were examined only for pain The authors are grateful to the people who participated in
and fatigue symptoms, so it is not known whether the study; Umut Kalyoncu, MD, who helped recruit study
other symptoms may be equally impacted by these subjects in the rheumatology clinic; and Marie Bakitas,
interventions. DNSc, CRNP, who edited the manuscript.

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