ORIGINAL RESEARCH
The Effects of Reflexology on Fatigue and
Anxiety in Patients With Multiple Sclerosis
Afitap Ozdelikara, PhD; Seval Agcadiken Alkan, PhD
ABSTRACT
Context • Multiple sclerosis (MS) is an inflammatory,
demyelinating disease of the central nervous system. In
addition to the progressive nature of the disease,
devastating symptoms adversely affect the patient’s daily
life and future expectations. This situation leads patients
to seek complementary and alternative treatments.
Objectives • This study was conducted to determine the
effects of reflexology on fatigue severity and anxiety in
patients with MS.
Design • The research was a quasi-experimental,
pretest-posttest design.
Setting • The research was conducted at the Mavi Işıklar
Rehabilitation Center of the Metropolitan Municipality of
Samsun (Samsun, Turkey), in cooperation with the
Faculty of Medicine’s Hospital Neurology Clinic and the
Health Application and Research Center at Ondokuz
Mayıs University (Samsun, Turkey), and with the Black
Sea MS Association.
Participants • Participants were patients who participated
in the MS Patient School program at the center and who
had been diagnosed with MS at least 1 y prior to the start
of the study.
Afitap Ozdelikara, PhD, is an assistant professor in the
Department of Internal Medicine Nursing, and
Seval Agcadiken Alkan, PhD, is an assistant professor, in the
Department of Fundamental Nursing, Health Faculty,
Ondokuz Mayıs University, in Samsun, Turkey.
Corresponding author: Afitap Ozdelikara, PhD
E-mail address: afitapozdelikara@gmail.com
M
ultiple sclerosis (MS) is an inflammatory,
demyelinating disease of the central nervous
system.1 Many chronic diseases related to the
neurological system can cause severe limitations and disability
in patients.2,3 MS also plays an important role in those diseases.
8 ALTERNATIVE THERAPIES, JUL/AUG 2018 VOL. 24 NO. 4
Inventions • Reflexology was applied for 60 min, 30 min
for each leg. Reflexology was conducted in an ergonomic
and positionable bed in a special physiotherapy room
within the Mavi Isiklar resting facilities.
Outcome Measures • Sociodemographic data forms, a
fatigue severity scale (FSS), and a state-trait anxiety
inventory (STAI) were used in the data collection.
Results • Fifteen patients participated in the study. The
average age of the participants was determined to be
39.20 ± 11.89 y. Before the participants received
reflexology, the average FSS score was 40.06 ± 19.27; the
mean (±SD) STAI-S score was 50.33 ± 9.48; and the mean
(±SD) STAI-T score was 43.33 ± 9.48. The average FSS
score after reflexology was 27.66 ± 21.23; the mean (±SD)
STAI-S score was 37.53 ± 10.11; and the mean (±SD)
STAI-T score was 31.86 ± 10.27.
Conclusions • The study indicates that reflexology can be
an effective method for reducing fatigue severity and
anxiety in patients with MS. (Altern Ther Health Med.
2018;24(4):8-13.)
MS is among the leading causes of neurological
disability in adults, regardless of trauma. 4,5
Myelinated-sheath injury causes neurotransmission
blockade, and various clinical symptoms arise due to motor,
sensory, visual, and cognitive dysfunction as well as issues
with sexual functioning and muscle discoordination,
depending on the affected area.6
As the disease progresses, clinical consequences of
injury to the axon occur, and functional loss happens at
different levels. Although those symptoms initially appear
only during exacerbations, they gradually settle with the
progression of the disease, affecting the quality of life and
self-efficacy of the patient.7,8 Numerous patients who do not
benefit from disease-modifying drugs and most patients with
MS have turned to alternative therapies.9
Ozdelikara—Reflexology, Fatigue, Anxiety, and MS
 Complementary therapies may offer an option for
diseases that require long-term symptom management, such
as MS.10 Having a chronic illness can lead to the use of
complementary therapies because patients (1) are dissatisfied
with the outcomes of modern medicine, (2) believe that
complementary therapies are natural and harmless, (3) want
control in their health decisions, (4) want to manage their
symptoms, (5) want to strengthen their immune systems, and
(6) want to reduce drugs’ side effects.11-22
Reflexology is very popular among the complementary
therapies.23 It provides massage of the reflex points in the
ears, hands, and feet, which practitioners consider to be a
small mirror of the specific organs and regions of the body.
Reflexology is a form of massage that regulates mixed-body
functions and, thus, provides relief and relaxation.24-25
Reflexology is frequently used to manage symptoms of
cancer patients and to increase their quality of life and can
also be used to adjust the sympathetic nervous system (SNS)
and the parasympathetic nervous system (PNS). It can
(1) regulate SNS and PNS functioning; (2) strengthen the
immune system; (3) regulate circulation; (4) shorten the
duration of infections; (5) decrease stress, anxiety, agitation,
tension, depression, fatigue, and insomnia; (6) reduce
constipation and nausea and vomiting in irritable bowel
syndrome; (7) lessen dermatological problems; (8) reduce
head, back, waist, muscle, and migraine pain; (9) improve
sinusitis, asthma, eczema, and some allergies26,27,28;
(10) reduce inflammatory urinary symptoms; (11) provide a
sense of general well-being, body awareness, and fitness in
patients with MS; and (12) help regulate sleep.29-30
According to the literature, fatigue is experienced by
one-third of patients with MS31 and is one of the most serious
and common symptoms.32,33 Fatigue in MS is “a subjective
physical or mental energy deficiency, which is perceived by
the individual or caregiver and cannot be [resolved] by the
individual’s usual activities.”34
Fatigue is a subjective finding and is determined by the
patient’s feelings and is shaped by the individual’s perception
of it.31,34 Therapies that help reduce its effects have been the
subject of various studies.
In a randomized, controlled trial with patients with MS,
Hossein et al35 stated that participants had been treated for
5 weeks with massage and showed decreased fatigue and
spasticity and improved walking resistance and balance. The
positive effects of massage on fatigue may be explained by the
removal of lactic acid, but little evidence is available to
support that explanation.36
Hughes et al37 found that reflexology performed with
patients with MS for 10 weeks reduced their fatigue severity.
Nazari et al38 reported in their study conducted with
75 patients with MS that reflexology decreased their fatigue,
and fatigue severity was found to be lower in the reflexology
group compared with the control group in the follow-up
conducted 2 months later.
Reflexology has been reported to reduce fatigue in many
studies conducted with cancer patients.27,39,40 A systematic
Ozdelikara—Reflexology, Fatigue, Anxiety, and MS
review by Lee et al41 found that 15 studies have been
conducted to determine the effects of reflexology on fatigue
and that reflexology was effective in reducing fatigue.
In their study with hemodialysis patients, Unal and Avcı42
also reached the conclusion that reflexology can reduce
fatigue. Reflexology has been shown to reduce stress and
anxiety and provide intense relaxation; ensure the circulation
of energy, opening the energy channels blocked throughout
the body; and reduce fatigue symptoms by removing toxins
from the body.43-46
Williamson et al47 reported that reflexology in women
with menopause reduced anxiety and depression compared
with standard foot massages. In a study with patients using
mechanical ventilators, reflexology was reported to reduce
anxiety and the physiological symptoms of anxiety
(ie, a higher pulse and blood pressure).48 Patients with
dementia who received reflexology showed a lower average
score for anxiety than a control group.49
In the studies evaluating the efficacy of reflexology in
cancer patients, reflexology was shown to have positive
effects in reducing anxiety.43,44,50 Ross et al51 found that
reflexology provided a reduction in anxiety and depression in
patients. As stated in the literature, reflexology provides
energy flow in the body, removing toxins, accelerating blood
circulation, and reducing stress and tension in patients.45,52
Reflexology also has been shown to provide stress relief and
mind/body balance to reduce stress-related symptoms and
stress levels.53
The current study was conducted to determine the effects
of reflexology on fatigue and anxiety in patients with MS.
METHODS
Participants
This study was conducted in a pretest-posttest,
quasi-experimental design. The research was carried out
from May 26, 2014, to May 31, 2014, and from November 3,
2014, to November 8, 2014. The study was conducted at the
Mavi Işıklar Rehabilitation Center of the Metropolitan
Municipality of Samsun, in cooperation with the Faculty of
Medicine’s Hospital Neurology Clinic and the Health
Application and Research Center at Ondokuz Mayıs
University (Samsun, Turkey) and with the Black Sea MS
Association.
Prospective participants were 27 patients who
participated in the MS Patient School program at the center.
They were included in the study if they (1) were older than
18 years; (2) knew their diagnoses; (3) had been diagnosed
with MS at least 1 year prior to the start of the study; (4) had
never received reflexology therapy previously; (5) were
literate in Turkish; and (6) did not suffer from hemorrhage,
epilepsy, fever, paraplegia, thrombosis, gall or kidney stones,
varicose veins in the leg or foot disease (ie, an open wound
or fracture on the foot), or a diagnosis of a psychiatric
disorder or dementia. Prospective participants were
excluded from the study if reflexology was not
contraindicated for them.
ALTERNATIVE THERAPIES, JUL/AUG 2018 VOL. 24 NO. 4 9
 Institutional and individual permits were obtained for Table 1. Participants’ Sociodemographic Data Distribution
the execution of the study. After patients were informed
about the study and their questions were answered, their Sociodemographic Characteristics n %
written and verbal consents were obtained. Gender
Female 12 80
Procedures Male 3 20
Sociodemographic data forms, a fatigue severity scale Marital status
(FSS) and the state-trait anxiety inventory (STAI) were used Married 7 46.7
in data collection at baseline and postintervention. The Single 8 53.3
participants were provided brief information about Education
reflexology upon agreeing to participate; afterward, the Primary school 8 53.3
participants completed the sociodemographic data forms, High school 5 33.3
the FSS, and the STAI. University 2 13.3
Employment
State officer 2 13.3
Interventions
Volunteer or multiple employers 4 26.7
The therapist had received theoretical and practical
Homemaker 9 60.0
training by participating in reflexology courses conducted at
Duration of the disease
the Psikoakademi Center and the London School of
3-5 y 3 20
Reflexology (London, United Kingdom). The reflexology was
6-8 y 2 13.3
administered by that member of the research team, and the
9+ y 10 66.7
outcomes were evaluated by the other members.
The therapist first cleansed the participant’s feet.
Prior to doing so, the therapist washed his or her hands The validity and reliability studies for Turkey were
with an antibacterial soap. The participant’s feet were conducted by Armutlu et al31 in 2007, and the Turkish
cleansed according to his or her preference, either by version was found to be valid and reliable. Participants’
washing his or her feet with water or using a disposable scores indicated their fatigue states for the month prior to
wet cloth. The participant’s joint points were supported by the test, including the day when the scales were
laying him or her in a supine position on a bed. The completed.54-55
therapist stood at the end of the participant’s bed during State-Trait Anxiety Inventory. The STAI was developed
the treatment. by Spielberger et al.56 It was adapted to Turkish by Öner and
Each reflexology session took approximately 60 minutes, Le Compte.57 The STAI is a self-evaluation scale consisting of
30 minutes for each leg. The reflexology was conducted in an short statements. The scale includes 40 items to measure the
ergonomic and positionable bed in a special physiotherapy state anxiety and constant anxiety variables, and each variable
room within the Mavi Isiklar resting facilities. is measured using 20 items.
Each session started with a massage on the right foot and The state anxiety scale (STAI-S) was developed to
continued to the left one. First, primary relaxation techniques determine how individuals feel in certain moments and
were performed on both feet; then, reflexology techniques under certain conditions. The trait anxiety scale (STAI-T)
were performed on all system organs. was designed to determine how individuals feel in general,
To provide slipperiness necessary to performance of the regardless of their current circumstances and conditions.
reflexology, scentless baby oil was used at room temperature. Emotions or behaviors expressed in the STAI-S are scored
The participant’s foot was relaxed by applying primarily using 1, never; 2, somewhat; 3, much; and 4, completely.
effleurage, shaking, and rotation and stretching methods. The STAI-S is followed by the STAI-T. In responding to the
During the therapy, one hand of the therapist supported the STAI-T, the feelings, thoughts, or behaviors represented by
participant’s foot, and the therapist used the other hand’s the items are scored by choosing 1 of the following scores:
fingers. A caterpillar technique with the thumb was mostly 1, almost never; 2, sometimes; 3, a lot of the time;
used. Organs of the gastrointestinal and urinary systems were or 4, always. The scales include 2 kinds of expressions:
the primary focus on both feet. The practice ended with solar- direct and reverse. A high score indicates a high anxiety
plexus pressure on both feet. level. The scores obtained from both scales are theoretically
between 20 and 80.
Outcome Measures
Fatigue Severity Scale. The Turkish version of the FSS Statistical Analysis
was used in the evaluation of fatigue levels.1 The scale The data was analyzed with the SPSS 22.0 package
consists of 9 questions. Each question is scored between program (IBM, Armonk, NY, USA), whereas percentage
1 (I do not agree) and 7 (I fully agree). The FSS score is the calculations, averages for the FSS and means ± standard
average value of the scores for the nine sections. A high score deviations (SD)s for the STAI, and Wilcoxon 2-sample tests
shows increased fatigue severity. were used for the statistical analysis.

10 ALTERNATIVE THERAPIES, JUL/AUG 2018 VOL. 24 NO. 4 Ozdelikara—Reflexology, Fatigue, Anxiety, and MS
Table 2. Participants’ Scores on the FSS and Mean Scores on the STAI
Baseline Postintervention
Measure Mean ± SD Mean ± SD Z Values P Values
FSS 40.06 ± 19.27 27.66 ± 21.23 -2.002
Constant Anxiety (STAI-T) 50.33 ± 9.48 37.53 ± 10.11 -2.670
State Anxiety (STAI-S) 43.33 ± 9.48 31.86 ± 10.27 -2.953
Abbreviations: FSS, fatigue severity scale; STAI, state-trait anxiety ınventory; SD, standard deviation.
RESULTS
Fifteen patients participated in the study. Their average
age was 39.20 ± 11.89. Of the 15 participants, 80% were
female; 53.3% were single; 53.3% were graduates of primary
school; 60% were housewives; and 66.7% had had MS disease
for 9 years or longer (Table 1).
Participants’ average scores on the FSS and mean
scores ± SD on the STAI are given in Table 2. Their average
FSS score was 40.06 ± 19.27 at baseline and was reduced to
27.66 ± 21.23 postintervention. The difference was statistically
significant (P = .045).
Participants’ mean score ± SD on the STAI-T at baseline
was 50.33 ± 9.48 and was decreased to 37.53 ± 10.11
postintervention. The difference was found to be statistically
significant (P = .008). Participants’ mean score ± SD on the
STAI-S at baseline was 43.33 ± 9.48 and was reduced to
31.86 ± 10.27 postintervention. The difference was statistically
significant (P = .003).
DISCUSSION
Nurses must be informed about complementary
therapies for those practices to be effective and to prevent any
mishaps and mistreatment of patients.58 Changes in the roles
and responsibilities of nurses have occurred with
advancements in technology and accumulation of scientific
knowledge in the field of health care. In that context,
complementary therapies can lie within the scope of the roles
of professional independent nurses, who have theoretical
knowledge and scientific know-how.58-60
Using their scientific knowledge, nurses can play an
analytical role that includes determining whether
complementary methods have been found to be valid and
reliable or have negative effects.58 Medical professionals
expect nurses to develop nursing applications related to the
use of complementary therapies, to determine effective
strategies, and to lead healthy individuals and/or patients in
using complementary therapies effectively and correctly.
Analysis of the literature indicates that complementary
therapies can be applied as nursing initiatives. Reflexology is
among those that can be directly integrated by nurses in their
applications.61-62
When the requirements of a holistic approach are taken
into consideration, including complementary therapies, it
falls on nurses to inform and lead patients who have been
diagnosed with chronic illnesses such as MS, in finding
solutions for their chronic symptoms.
Ozdelikara—Reflexology, Fatigue, Anxiety, and MS
.045
.008
.003
Within that scope, nurses can conduct studies revealing
the efficacy of complementary therapies, such as reflexology,
that can be integrated into their work, and they should create
awareness of them. MS is a progressive disease that causes
disability and loss of the ability to work, seriously affecting
the lives of people at a productive age.63
Some drugs used in MS treatment have side effects and
limited effects on the immune response.-64 Complementary
and alternative medicine methods are preferred primarily for
the following reasons: (1) the lack of support for
complementary therapies in health-insurance systems;
(2) the side effects of drugs or treatments; (3) high treatment
and drug fees; (4) the lack of control in individual health care
practices; (5) the use general, technological, medical methods
not specific to individuals in conventional medicine; and
(6) the ability of complementary therapies to boost the
immune system, support healthy behaviors, and reduce
patients’ feelings of hopelessness.65-70
Research on the use of reflexology in patients with MS,
however, is limited. The current study’s goal was to determine
the effects of reflexology on fatigue, state, and trait anxiety in
patients with MS have been discussed with the related
literature. Pre- and postreflexology test measurements
conducted on the current study’s participants are given in
Table 2. That data show that their fatigue severity scores
decreased markedly, and the difference between their average
scores for fatigue severity at baseline and postintervention
was statistically significant.
When participant’s baseline and postintervention
average scores for trait anxiety and state anxiety were
compared in the current study, the research team also found
that those scores had decreased and were statistically
significant.
Limitations
The application of reflexology by one member of the
research team constitutes one limitation of the current study.
The lack of a sufficient number of reflexology therapists in
Turkey led to the reflexology application being carried out by
that team member. However, the observance of ethical
research principles prevented the study’s findings from being
affected. The research team proposes to increase the number
of participants in future studies and to investigate the effects
of reflexology on other symptoms of MS.
ALTERNATIVE THERAPIES, JUL/AUG 2018 VOL. 24 NO. 4 11

CONCLUSIONS
The current research determined that reflexology had
positive effects on fatigue and anxiety in patients with MS.
The current study’s results confirmed the hypothesis that
reflexology can have positive effects on fatigue and anxiety in
patients with MS. In line with that result, the current research
team believes that the use of reflexology to reduce tiredness
and anxiety in patients with MS could play a supporting role
in increasing the quality of life and sustaining the daily
activities of patients. To lower the fatigue and anxiety levels
of patients with MS, the benefits of reflexology applied by
certified reflexologists should be shared with patients,
relatives, and health care workers. This guidance and
counseling by health personnel is extremely important in
terms of patients’ safety.
ACKNOWLEDGEMENTS
The research team would like to thank Associate Professor Murat Terzi and the team of
the MS Patient School project for providing the appropriate facilities to conduct the
research.
AUTHOR DISCLOSURE STATEMENT
The authors have no conflicts of interest to disclose.
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