http://doi.org/10.33698/NRF0140  Jasvir Kaur, Sukhpal Kaur, Neera Bhardwaj

Abstract: ‘Foot massage and reflexology’ is one of the commonest method of complementary therapies. Massage therapy and reflexology are manual therapeutic approaches used to facilitate healing, health and can be used by nurses in almost any setting. The present study was conducted to assess the effect of ‘foot massage and reflexology’ on physiological parameters i.e systolic and diastolic blood pressure, heart rate and oxygen saturation of critically ill patients. The study was carried out in five intensive care units. Using purposive sampling, 60 patients were enrolled in this study. A protocol on the procedure of ‘foot massage and reflexology’ was developed. An Observation checklist was used to record the various parameters. Controlled observations for all the physiological parameters under study were recorded for the first three days in the morning as well as in the evening hours with the total of six observations. Then, for the next three days the procedure of ‘foot massage and reflexology’ was implemented on the same patients. All the physiological parameters were recorded just before and after the implementation of protocol on each day in the morning as well as in the evening hours. Mean age (yrs) ±SD of study subjects was 46.7 ±16.1 and 70% were male.During the controlled observations there was no significant difference in any of the physiological parameters. There was significant decrease in the systolic blood pressure, increase in diastolic blood pressure, reduction in the heart rate and improvement in the oxygen saturation in some interventional observations after the intervention. But, no statistically significant difference was found on the abnormal category of the blood pressure and heart rate. So, because of the positive results of the intervention, the nurse practitioners may be trained about the technique of foot massage and reflexology.

Key words :Physiological parameters, critically ill patients, foot massage and reflexology.
Correspondence  at Jasvir kaur V.P.O Partabpura, Teh: Phillaur Distt: Jalandhar, Punjab
Introduction:Nursing is a profession based on art and science. This means that a professional nurse learns to deliver care artfully with compassion. Care should always change with new discoveries and innovations. When nurses integrate the science and art of nursing into their practice, the quality of care provided to the patients is at a level of excellence that benefits in innumerable ways.1Intensive care unit(ICU) provides care to patients who are seriously ill and require 24-hour care and monitoring.2As per Fernandaz et al 13.9% ICU mortality rate was due to physiological parameters alteration.3 According to the National Center for Complementary and Alternative Medicine (NCCAM), complementary therapy is a group of diverse medical and health care systems.4Katai found that use of alternative and complementary medicine is increasing worldwide. The most frequently used methods were homeopathy (34.6%) and reflexology (18.7 %).5 Touch therapy has always been a part of the nursing care and now reflexology has become a part of this. A nurse researcher wrote that the foot reflexology is a way to enhance the nurse-patient interrelationship as a nurse can easily and practically use massage. It offers a strategy to fulfill the goals of human touch and holistic care. It can be performed at any location, is a non-invasive and does not interfere with patient’s privacy.6Reflexology is based on the principle that the hands and feet are mirrors of the body and they have reflex points that correspond to each of the body’s gland, structure and organs. It is believed that when a reflex area is massaged, it stimulates the corresponding organs in that zone.7 Massage has mechanical effects that improve circulation, remove waste products from the body, improve joint mobility, relieve pain and reduce muscle tension. It has psychological benefits such as relaxation and it improves sense of well-being.8 A study showed that foot reflexology is effective in changing renal blood flow.9Labyak and Metzger evaluated the efficacy of massage and its effect on the physiological measures of relaxation. They concluded that the long, slow, gliding strokes of a massage are associated with a reduction in heart rate and respiratory rate.10 Another study showed the effect of five- minute foot massage on physiological parameters of the critically ill patients. Results indicated that foot massage had the potential effect of increasing relaxation as there were physiological changes after the intervention of foot massage.11 Won and colleagues found that there was significant difference in systolic blood pressure, diastolic blood pressure, pulse rate, general fatigue, and mood status after giving foot massage. So they recommended using foot reflexology as an effective nursing intervention in cancer patients.12 Today nursing is focusing on holistic health care and it is believed that complementary therapies are also a part of holistic nursing. ‘Foot massage and foot reflexology ‘helps in improving the circulation of the blood and assists in relaxation of the patients. So in this preview, the current study was conducted to assess the effect of ‘foot massage and reflexology’ on physiological parameters of critically ill patients.
Material and Methods:A quasi experimental research design was employed. Study was conducted in the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. PGIMER, Chandigarh is a ter tiary care hospital, caters to the need of sick and has about 50,000 annual admissions.It has various ICUs which are providing care to the seriously ill patients, main ICU, liver ICU, respiratory ICU, cardio thoracic ICU and gastroenterology ICU of Nehru hospital was selected for the current study. Using purposive sampling technique, patients who were admitted in above said ICUs during 15 July-31 August 2011 were included in the study. Patient with foot ulcers and foot fracture were excluded from the study.60 subjects were enrolled in this study.Permission was obtained from the head, Deptt of selected ICUs, PGIMER, Chandigarh.Informed written consent was obtained from the patient’s attendants. The study was approved by Institute Ethical Committee. The tools used for data collection were sociodemographic and clinical data sheet, protocol for ‘foot massage and reflexology’ technique and an observation checklist to record the physiological parameters. Tool was prepared by reviewing the literature and with the help of guide and co-guide. It was validated by the experts from the field of nursing education and medicine.The sociodemographic data sheet consisted of items like name, age, sex, C.R no, bed no, ward, date of admission, diagnosis, educational status, occupation, total family members, total family income and per capita income etc. Clinical data consisted of items such as duration of stay in the intensive care unit, nutrition, surgery performed(if any), level of consciousness, body built,respiratory devices, physiological parameters and pharmacological treatment. ‘Foot massage and reflexology’ protocol consisted of steps which were followed while applying the technique.The various steps followed were sweeping and rubbing, thumb walking, toe rotation, kneading and cupping.Data was collected in the month of July and August 2011. For first three days, the physiological parameters of each subject were observed twice a day (morning and evening) and recorded. For the next three days, intervention (foot massage and reflexology) was implemented on the same patients twice daily(in the morning and evening hours) as per protocol. All the physiological parameters i.e the systolic BP, diastolic BP, heart rate, oxygen saturation were recorded just before and after the intervention by using Observation checklist.The data was analyzed as per objectives using both descriptive and inferential statistics. The effect of foot massage and reflexology was recorded on physiological parameters by using various statistical measures i.e frequency distribution, measures of central tendency (mean, mode), measure for dispersion (range, standard deviation), paired t-test and ANOVA. P values were considered at 5% and 1% level of significance.
Results:Sociodemographic data of the subjects
Table 1 shows the socio-demographic data of the subjects. Mean age (yrs) ±SD of the subjects was 46.7±16.1, with the range of 16-80 yrs. Around one third (31.6%) were between 31-45 years. Majority (70%) were male. 30% were illiterate. 28.3% were self employed. Around half (53.3%) of the subjects had 1-5 family members in their families.
Variables n(%)
*Age (yrs)
15-30 12(20.0)
31-45 19(31.6)
46-60 16(26.7)
>61 13(21.7)
Sex
Male 42(70.0)
Female 18(30.0)
Educational Status
Illiterate 18(30.0)
Just literate 14(23.3)
Metric 10(16.7)
Senior secondary 06(10.0)
Graduate & above 12(20.0)
Occupation
Student 03(05.0)
Govt.service 07(11.6)
Self employed 17(28.4)
Housewife 13(21.7)
Laborer 04(06.6)
Not working 13(21.7)
Retired 03( 05.0)
**Total family members
1-5 32(53.3)
6-10 26(43.3)
?11 02( 3.4)

 

Table 1: Socio-demographic data of the subjects           N=60

were on Ryle’s tube feeding. As per Glassgow Coma Scale nearly half (51.7%) of the subjects were conscious. 53.3% were on ventilator support and one fourth subjects were on room air without any respiratory support. Most (71.7%) were having normal built as  per  their  Body   Mass Index (BMI). (Table 2)

Table 2: Clinical data of the subjects

 

Variables n(%)
ICU

Main ICU Liver ICU

Respiratory ICU

Gastroenterology ICU Cardiology ICU

 

15(25.0)

15(25.0)

13(21.7)

12(20.0)

05( 8.3)

*Duration of stay in ICU(days)

1-5

6-10

11-15

16-20

?20

50(83.3)

04(06.7)

02(03.3)

01(01.7)

03(05.0)

Type of nutrition Normal diet Diabetic diet

Renal diet Burn diet RT feed**

Any other***

10(16.7)

05( 8.3)

10(16.7)

10(16.7)

14(23.3)

11(18.3)

Undergone surgery

Yes No

Level of consciousness

(as per Glassgow Coma Scale) Unconscious

Semiconscious Conscious

06(10.0)

54(90.0)

 

21(35.0)

08(13.3)

31(51.7)

Body Built

(as per Body Mass Index) Underweight

Normal Overweight

 

07(11.7)

43(71.7)

10(16.6)

Respiratory Device

Ventilator T-tube Oxygen

Room air

32(53.3)

01( 1.7)

12(20.0)

15(25.0)

 

N=60

*Mean age (yrs) ±SD:46.7±16.1, Range: 16-80yrs

**Mean±SD:5.41±2.35, Range: 1-13

Clinical data of the subjects

One four th of the subjects were admitted in the main ICU and same number were admitted in liver ICU. Mean duration (days) of stay in ICUs was 4.2±6.96. Majority (83.3%) had 1-5 days of stay in ICUs. 23%*Mean duration of stay (days) ±SD:4.2±6.96, Range:1-37 **Burn+khichri diet, milk, juice ect through Ryle’stube***Hepatic diet, salt restricted diet, NPO. During controlled observations, no significant difference was observed in systolic BP, diastolic BP, and oxygen saturation. But in the heart rate, from first to fifth observation, there was significant increase in the controlled observation. During the post interventional observations, in the systolic BP, from the first observation to the four th observation, significant increase was recorded which was not toward the desire end. Otherwise, there was fluctuation in the other reading but the difference was not significant. In diastolic BP, from the first observation to the third, fourth and fifth continuous observation fluctuations were noted. In the heart rate of subjects, there was significant increase from first to third observation. But from first to sixth observation, heart rate was decreased. In oxygen saturation, the values were same in the controlled and post interventional observations.(Table 3 & 4)

Table 3: Physiological parameters (mean values) of the subjects during controlled and post interventional observation                                                                                          N=60

 

Physiological

Parameter

Observations Mean ± SD
01 02 03 04 05 06
 

Systolic blood pressure

mm kg

Controlled

observation

118.8 ±

22.6

121.8 ±

19.7

123.5 ±

22.0

123.9 ±

21.9

124.2 ±

20.1

123.4 ±

20.1

Post Interventional

observation

122.9±

17.2

124.8±

19.3

129.3 ± 19.2 130.4±

18.0

124.8±

20.5

125.8±

18.0

 

Diastolic blood pressure mmHg

Controlled

observation

69.8 ±

13.3

71.0 ±

14.3

70.7 ±

17.3

71.4 ±

15.8

73.3 ±

14.3

72.5 ±

12.6

Post Interventional observation 73.3 ± 13.6 73.1±

12.0

76.2 ± 13.3 75.5±

12.5

75.9±

15.2

77.7±

13.2

 

Heart rate

per minute

Controlled observation 95.4 ± 19.6 99.8 ± 20.4 100.5 ± 22.3 101.4 ± 22.1 100.2 ± 18.3 98.4 ± 18.9
Post Interventional

observation

98.8±

18.7

96.8±

20.4

101.0 ± 20.6 94.1±

17.1

98.6±

20.6

94.5±

16.8

 

Oxygen saturation

Controlled

observation

97.2 ±

4.0

97.7 ±

3.1

97.3 ±

3.7

97.8 ±

3.1

97.2 ±

3.7

97.8 ±

3.2

Post

Interventional observation

97.9 ±

3.0

98.3±

2.0

97.5 ±

2.8

98.1±

2.0

96.9±

3.5

97.8 ±

2.6

O1=observation 1, o2=observation 2…………… so on.

Table 4: Difference between Physiological Parameters of the Subjects during Controlled and Post Interventional Observation

 

Physiological Parameters Observations t, p values
O1vs O2 O1vsO3 O1vsO4 O1vsO5 O1vsO6
 

Systolic Blood Pressure

mmHg

Controlled

observation

-0.99, 0.32 -1.35, 0.18 -1.53, 0.13 -1.57, 0.12 -1.36, 0.17
Post

Interventional observation

-0.93, 0.35 -1.81, 0.07 -2.34, 0.05* 0.32, 0.97 -2.8, 0.77
Diastolic

Blood Pressure mmHg

Controlled

observation

-0.67, 0.50 -0.41, 0.68 -0.73, 0.46 -0.41, 0.68 -0.41, 0.68
Post Interventional

observation

0.15, 0.87 -2.68, 0.05* -3.89,0.001** -2.00, 0.05* -2.74, 0.08
Heart Rate

Per Minute

Controlled

observation

-0.73, 0.46 -0.73, 0.46 -1.91, 0.06 -2.30, 0.05* -1.89, 0.06
Interventional

observation

1.08, 0.28 -0.13, 0.89 3.48, 0.05* 0.76, 0.44 2.72,0.001*
Oxygen

Saturation

Controlled

observation

-1.12, 0.26 -1.18, 0.24 -1.18, 0.24 -3.35, 0.73 -1.18, 0.24
Post

Interventional observation

-1.23, 0.22 0.16, 0.87 -1.44, 0.15 -1.43, 0.15 -0.53, 0.59

*p<0.05, **p<0.01 01 – observation 1, 02 observation……………… go on

The immediate effect of foot massage and reflexology on the systolic blood pressure was recorded in the fourth and sixth observation as there was significant decrease (toward the normal range) in the systolic BP after intervention. (t=2.60, 2.24, p<0.05). Otherwise no significant effect was recorded in the other observations. The difference in the diastolic BP, in the second observation there was significant increase (toward the normal range) in diastolic BP (t=-2.79, p<0.01). There was significant reduction (toward the normal range) in the heart rate in the first, second, third and fifth observation after the intervention. (t=2.09, 2.14, 2.29, 4.07, p<0.05). After theintervention, there was significant improvement in the oxygen saturation in the second and fifth observation. (t=-4.21, -3.19, p<0.01) (Table 5& Fig 1)

Fig 1: Average Values of Physiological Parameters before and after the Intervention

 

Effect of intervention on physiological parameters (category wise):The subjects were categorized as per the normal and abnormal values of the blood pressure. The subjects with blood pressure of more than 140/90 mmHg (considered as hyper tensive) and less than 90/60mmHg(considered as hypotensive)was included in the abnormal category. Fisher exact test did not show any significant difference (p>0.05). Before the intervention 95% of the subjects had the normal BP. But after the intervention, this number increased to 96.7%.The effect of foot massage and reflexology was assessed on the normal and subnormal heart rate. The subjects with heart rate of less than 60 bpm (considered as bradycardia) and more than 100 bpm (considered as tachycardia) were included in abnormal category. Before the intervention 66.7% of the subjects had normal heart rate. But after the intervention, this number increased to 70%. But, results did not show any statistically significant difference (p>0.05) (Table 6)

Table 6: Effect of Intervention on Physiological  parameters  (Category Wise) N=60

 

Physiological

parameters

Before After
Normal BP (90/60-140/

90mmHg)

 

 

57(95.0)

 

 

58(96.7)

Abnormal

BP>140/90or

<90/60 mmHg

 

3(5.0)

 

2(3.3)

X2, df, p-value 0.21, 1, 1.00
Normal HR

(60-100 bpm)

 

40(66.7)

 

42(70)

Abnormal

HR>90or<60

bpm

 

20(33.3)

 

18(30)

X2, df, p-value 0.26, 1, 0.82

Table 5: Effect of Intervention on Physiological Parameters                      N=60

Physiological parameter O1 O2 O3 O4 O5 O6 Average
Systolic blood pressure
(mmHg)
-Before intervention 124.9 ± 20.2 124.8 ±19.3 129.3 ±19.2 130.4 ±18.0 124.8 ± 20.5 125.8±18.0 126.7±2.5
-After intervention 122.9 ± 17.2 124.3 ±16.9 128.5 ± 18.9 127.7 ±16.6 123.8 ±19.0 124.0±15.7 125.2±2.3
-t, p value 1.74, 0.08 0.55, 0.58 0.57, 0.57 2.60, 0.05* 1.41, 0.16 2.24, 0.05* 4.28, 0.08
Diastolic blood pressure
(mmHg)
-Before intervention 71.6 ± 13.9 73.1 ± 12.0 76.2 ± 13.3 75.5 ± 12.5 75.9 ± 15.2 77.7 ± 13.2 74.6±2.0
-After intervention 73.3 ± 13.6 75.1 ± 10.6 77.1 ± 11.1 80.0 ± 12.7 76.8 ± 14.4 77.8 ± 12.2 76.4±2.49
-t, p value -1.85, 0.06 -2.79,0.01** -0.84, 0.40 -1.63, 0.10 -1.49, 0.14 -0.20, 0.83 3.02,0.05*
Heart rate (bpm)
-Before intervention 100.7±18.3 96.8 ± 17.5 101.0 ± 20.6 94.1 ± 17.1 98.6 ± 20.6 94.5 ± 16.8 98.2±2.87
-After intervention 98.8 ± 18.7 94.6 ± 14.5 99.0 ± 21.0 92.5 ± 18.6 94.1 ± 18.6 92.1 ± 13.1 95.8±2.93
-t, p value 2.09, 0.05* 2.14, 0.05* 2.29, 0.05* 0.83, 0.41 4.07, 0.01** 1.93, 0.58 4.65,0.01**
Oxygen saturation
-Before intervention 97.6 ±3.2 98.3 ± 2.0 97.5 ± 2.8 98.1 ± 2.0 96.9 ± 3.5 97.8 ± 2.6 97.7±4.94
-After intervention 97.9 ± 3.0 98.7 ± 1.9 97.7 ± 2.8 98.3 ± 2.1 97.4 ± 3.3 98.8 ± 1.7 98.1±5.61
-t, p value -1.27, 0.21 -4.21,0.01** -1.39, 0.16 -1.21, 0.23 -3.19,0.01** -0.92, 0.36 -3.52,0.01**

O1=observation1, o2=observation 2………..so on.                                     *p<0.05, **p<0.01

Discussion:Reflexotherapy is one of the available interventions in complementary medicine and treatment which provides an opportunity for nurses to care for their patients.13 Massage therapy and reflexology are manual therapeutic approaches used to facilitate healing and health and can be used by nurses in almost any setting.14 Reflxotherapy has positive impact on the physiological parameters, so in comparison of these studies, to see the effect of foot massage and reflexology on physiological parameters i.e systolic blood pressure, diastolic blood pressure, heart rate and oxygen saturation, current study was conducted in the ICUs of Nehru Hospital, PGIMER, Chandigarh.As one study suggested that a foot reflexology massage could be utilized as an effective nursing intervention to reduce depression, stress responses and to strengthen immune systems in middle-aged women. There was a statistically significant difference in depression, perceived stress, systolic blood pressure, natural-killer cells and IgG after foot massage.15 Quattrinet al conducted a study on the anxiety level of the cancer patients and effect on their vital signs such as systolic blood pressure, diastolic blood pressure, heart rate and respiratory rate with reflexology. These were significantly decreased in vital signs after 30 minutes of reflexology.16 In the current study,there was decrease in the systolic blood pressure toward the normal range as there was statistically significant decrease in the fourth and fifth observation. In the diastolic blood pressure there was significant difference in the second and in the average of six observations. Diastolic blood pressure was increasing from first to fifth observation in current study. Hence showing immediate impact of foot massage and reflexology on physiological parameters.However, Park and Cho (2004) did not find any significant differences in diastolic blood pressure and LDL cholesterol level between the foot reflexology group and the control group, though, the intervention was effective in decreasing systolic blood pressure and triglycerides and in improving the life satisfaction amongst the patients.17 The effect of foot massage and reflexology was noted on the heart rate. There was reduction in the heart rate as before the intervention 66.7% were in normal category and after the intervention it was increased to 70%. There was statistically significant reduction in the heart rate (toward normal) of the subjects from the first observation to fourth and sixth observation. There was also immediate effect of intervention on heart rate. Moeini et al showed that the average systolic and diastolic blood pressure between the two groups of intervention and control had a significant difference after conducting the reflexotherapy. But, for the heart rate and respiration rate, the average changes in these parameters showed no significant statistical difference between the two groups. However, the results showed that in intervention group, the average heart rate and respiratory rate per minute had slightly decreased after the reflexotherapy.18 Frankal found that reflexology and foot massage group showed significantly greater reduction in baroreceptor reflex sensitivity as compared to control group. The frequency of sinus arrhythmia after reflexology and foot massage was increased by 43.9% and 34.1% respectively.19 In the current study, the effect of foot massage and reflexology was also assessed on the oxygen saturation level. In the second, third and average observation there was a statistically significant improvement in oxygen saturation level. Hayes and Cox used mean arterial blood pressure as an indicator of measurement of physiological and psychological stress in 25 patients in a critical care unit. They found that there was a significant decrease in heart rate, mean arterial blood pressure and respirations during the foot massage intervention as compared to
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