1. Background
Chronic respiratory diseases (CRDs) are often the most common non-communicable respiratory diseases in the world (1). High-income and developed regions have the highest prevalence of chronic respiratory diseases (2). The highest prevalence of respiratory diseases includes chronic obstructive pulmonary disease (COPD) (global prevalence of 3.9%) and asthma (3.6%) (3). Emerging and prominent studies highlight a series of more significant symptoms that dramatically impact patients' lives, such as shortness of breath, fatigue, and anxiety (4). Dyspnea is one of the common symptoms of these diseases, which can persist and rapidly worsen in patients. It also leads to activity limitation and impairs quality of life (3). Fatigue correspondingly increases with the severity of dyspnea (5). Increased fatigue can be accompanied by mood, mental, and physical fluctuations and disturb patients' daily activities, including self-care tasks (3). Anxiety is a common mental disorder, especially in patients with asthma, affecting 16% to 52% of asthma patients and 40% of COPD patients (6).
There are several non-pharmacological coping strategies for managing symptoms that nurses can implement as part of the healthcare team. These include patient education at home, respiratory exercises, progressive relaxation exercises, and reflexology (7). Foot reflexology is a systemic procedure in which the practitioner applies pressure on particular points of the foot sole to stimulate the body and bring health benefits to different parts (8). This type of treatment stimulates the nerves and blood circulation system of the body (9). Currently, the most promising theory suggests that the benefits of foot reflexology may be due to the autonomic nervous system, and it is well known that it relieves stress and anxiety symptoms by reducing anxiety and muscle tension (10).
Regarding the effect of foot reflexology on patients with respiratory problems, it can be mentioned that reflexologists improve lung function, relieve sinus problems and congestion, and relax stiff muscles by stimulating respiratory reflexes (11). A reflexology session can activate the diaphragm, stimulate the lungs, and strengthen the immune system (8). In a study on the effect of foot reflexology on the severity of fatigue and quality of life in hemodialysis patients, Habibzadeh et al. showed that foot reflexology using almond and chamomile oil has a positive effect on reducing fatigue and improving quality of life among hemodialysis patients (12).
2. Objectives
However, limited research exists on the impact of reflexology in CRD patients, particularly in Iran. This study seeks to investigate the effects of foot reflexology on fatigue, dyspnea, and anxiety among chronic respiratory patients, aiming to contribute valuable insights into its potential as a complementary therapy.
3. Methods
3.1. Design
This study employed a two-group pre-test and post-test quasi-experimental design, structured as a clinical trial.
3.2. Participants
The present study is a quasi-experimental clinical trial conducted on hospitalized patients with CRDs presenting moderate to severe lung involvement, who were admitted to teaching hospitals affiliated with Abadan University of Medical Sciences. After obtaining ethical approval from the Ethics Committee of Abadan University of Medical Sciences (ethical code: IR.ABADANUMS.REC.1400.156), along with a formal introduction letter and coordination with the educational and research vice-chancellors of the above hospitals, CRD inpatients (including those with COPD, asthma, and bronchitis) were evaluated, and 40 eligible patients were selected through purposive sampling based on the inclusion criteria.
To ensure comparability between the intervention and control groups, a matching procedure was implemented. Patients were matched based on key clinical variables likely to influence disease progression and recovery, including age, sex, severity of lung involvement, and the presence of comorbidities. After matching, participants were randomly assigned to either the intervention or control group (n = 20 in each group).
The inclusion criteria comprised having relative independence in performing activities of daily living, maintaining a state of consciousness, a diagnosis of CRDs with moderate to severe lung involvement, and willingness to participate in the study. The exclusion criteria included decreased level of consciousness, leg problems (e.g., blood supply issues, numbness, tissue wounds, or amputations), pregnancy, psychotic disorders, severe liver, heart, or kidney diseases, and the use of other complementary or alternative therapies.
3.3. Sample Size
The sample size was calculated using an effect size of 0.90 from Habibzadeh et al., with a 95% confidence interval and 80% power, requiring at least 16 participants per group (12). To allow for a 25% dropout rate, each group included 20 participants.
3.4. Intervention
The intervention group received foot reflexology sessions twice weekly for six weeks (30 minutes per session) using sweet almond oil. Sessions included general massage for 5 minutes, using circular finger movements, and focused massage for 10 minutes per foot, targeting reflex points for the lungs, solar plexus, and pituitary gland. Both feet were massaged in the supine position. Standardized techniques were performed by two trained therapists (one male, one female) who had undergone targeted reflexology training. These therapists were selected to deliver the intervention and were trained using a standardized video-based educational program specifically developed for reflexology interventions. The training included comprehensive instructional videos covering reflexology principles. To ensure mastery, the therapists were required to complete a practical evaluation supervised by senior nursing faculty members experienced in complementary therapies. To mitigate psychological bias, the control group received a general oil-free foot massage. Reflexology protocols adhered to strict hygiene practices, with therapists and patients sanitizing hands and feet before sessions. Outcome assessments were conducted two weeks post-treatment by a blinded colleague.
3.5. Questionnaires
Data collection tools include a Socio-demographic Characteristics Questionnaire, which includes questions on level of education, relationship with relatives, and economic status, as well as the Spielberger State-Trait Anxiety Inventory (STAI), the Fatigue Severity Scale (FSS), and the Borg Dyspnea Scale. Each state-trait anxiety inventory consists of 20 items that are answered based on a four-point Likert scale for items with a positive attitude (1, 2, 5, 8, 10, 11, 15, 16, and 20), with options ranging from almost never (4), sometimes (3), most of the time (2), to almost always (1). Options with a negative attitude (items 3, 4, 6, 7, 9, 12, 13, 14, 17, and 18) are scored inversely. The positive items (1, 3, 6, 7, 10, 11, 13, 14, 16, and 19) and negative items (5, 8, 9, 12, 17, 18, and 20) are calculated as above in the state anxiety inventory. Scores of 20 - 30, 31 - 42, 43 - 53, and 54 and more indicate no or minimum, mild, moderate, and severe anxiety in the trait anxiety inventory. Similarly, scores of 20 - 34, 35 - 45, 46 - 56, and 57 and more indicate no or minimum anxiety, mild, moderate, and severe anxiety in the state anxiety inventory, respectively. In Iran, Zakerimoghadam et al. reported Cronbach's alpha coefficients of 0.90 and 0.92 for the trait and state anxiety scales, respectively (13). The content validity of STAI has been confirmed with a Cronbach's alpha coefficient of 94% in the study by Malakoutikhah et al. (14). The FSS scores of 4 and above indicate severe fatigue, while scores less than 4 indicate moderate or mild fatigue. Fatigue is confirmed if the sum of the total scores is equal to or greater than 36, with higher scores indicating a higher degree of fatigue. The Borg Dyspnea Scale is a standard numerical scale mentioned by Daneshmandy et al., where a psychometric and correlation coefficient of 0.84 and a reliability coefficient of 0.78 are reported for it (15). In this scale, each score (0 to 10) indicates the respiratory condition, with scores of 0 and 10 indicating no dyspnea and peak dyspnea, respectively.
3.6. Data Analysis
Data were analyzed using SPSS version 19. Descriptive statistics, including mean and standard deviation, were used to summarize outcomes. Inferential analyses included paired t-tests and multivariate regression to assess the intervention's impact and control for confounding variables. Statistical significance was set at P < 0.05.
4. Results
4.1. Characteristics of the Study Population
The study included 40 patients, with six excluded due to health deterioration, death, or loss to follow-up, leaving 34 participants (N = 17 per group). Most participants in the intervention group were female, had a mean age of 57, were illiterate or had at least a diploma, had an average income, moderate disease severity, and a history of cardiovascular and respiratory diseases (Table 1).
Table 1.Characteristics of the Study Population (N = 34) a
| Characteristic | Intervention Group | Control Group |
|---|---|---|
| Gender; No. | ||
| Male | 6 | 16 |
| Female | 28 | 18 |
| Age; mean ± SD | 57.352 ± 14.907 | 43.823 ± 11.292 |
| Education | ||
| Illiterate | 7 (41.18) | 4 (23.53) |
| Under diploma | 3 (17.62) | 6 (35.29) |
| Diploma and higher | 7 (41.18) | 7 (41.18) |
| Economic status | ||
| Satisfied | 3 (17.65) | 1 (5.88) |
| Moderate | 13 (76.47) | 9 (52.94) |
| Weak | 1 (5.88) | 7 (41.18) |
| Severity of diseases | ||
| Moderate | 12 (70.59) | 9 (52.94) |
| Sever | 5 (29.41) | 8 (47.06) |
| Medical history | ||
| Diabetes | 1 (2.94) | 5 (14.71) |
| Cardiovascular | 2 (5.88) | 3 (8.82) |
| Diabetes and respiratory | 1 (2.94) | 0 |
| Diabetes and cardiovascular | 0 | 2 (5.88) |
| Diabetes and cardiovascular and respiratory | 3 (8.82) | 0 |
| Cardiovascular and respiratory | 4 (11.76) | 0 |
| Renal | 1 (2.94) | 3 (8.82) |
| Respiratory | 3 (8.82) | 3 (8.82) |
| No medical history | 2 (5.88) | 1 (2.94) |
a Values are expressed as No. (%) unless otherwise indicated.
4.2. Effect of Reflexology on Fatigue
The paired t-test revealed a significant reduction in fatigue scores after the intervention (P = 0.02), while no significant change was observed in the control group (P = 0.52) (Table 2).
Table 2.Effect of Reflexology on Fatigue
| Fatigue | Mean ± SE | SD | Confidence Interval (95%) | P-Value |
|---|---|---|---|---|
| Intervention group (N = 17) | 0.02 | |||
| Before the intervention | 38.76471 ± 0.9759212 | 4.023826 | 36.69585 | |
| After the intervention | 35.58824 ± 1.124784 | 4.637602 | 33.2038 | |
| Control group (N = 17) | 0.52 | |||
| Before the intervention | 38.47059 ± 1.160368 | 4.784319 | 36.01072 | |
| After the intervention | 38.58824 ± 1.060864 | 4.374055 | 36.3393 |
4.3. Effect of Reflexology on Dyspnea
The paired t-test showed a significant reduction in dyspnea levels in the intervention group after foot reflexology (P = 0.00), while no significant change was observed in the control group (P = 0.63) (Table 3).
Table 3.Effect of Reflexology on Dyspnea
| Dyspnea | Mean ± SE | Confidence Interval (95%) | P-Value |
|---|---|---|---|
| Intervention group (N = 17) | 0.00 | ||
| Before the intervention | 5.235294 ± 0.4070104 | 4.407225 | |
| After the intervention | 2.823529 ± 0.2460765 | 2.322883 | |
| Control group (N = 17) | 0.63 | ||
| Before the intervention | 5.941176 ± 0.3261923 | 5.277533 | |
| After the intervention | 5.705882 ± 0.3714509 | 4.95016 |
4.4. Effect of Reflexology on Anxiety
The study showed a significant reduction in STAI scores in the intervention group after foot reflexology (P = 0.00). However, no significant change was observed in the control group after the oil-free simple massage (P > 0.05) (Table 4).
Table 4.Effect of Reflexology on Anxiety
| Anxiety | Mean ± SE | Confidence Interval (95%) | P-Value |
|---|---|---|---|
| Intervention group (N = 17) | 0.00 | ||
| Manifest anxiety | |||
| Before the intervention | 65.58824 ± 1.645088 | 62.24128 | |
| After the intervention | 46.82353 ± 2.277181 | 42.19057 | |
| Hidden anxiety | 0.00 | ||
| Before the intervention | 57.17647 ± 1.301117 | 54.52933 | |
| After the intervention | 43.41176 ± 1.878788 | 39.58934 | |
| Control group (N = 17) | 0.59 | ||
| Manifest anxiety | |||
| Before the intervention | 49.41176 ± 2.353125 | 44.6243 | |
| After the intervention | 51.05882 ± 1.960024 | 47.07112 | |
| Hidden anxiety | 0.57 | ||
| Before the intervention | 43.94118 ± 2.151386 | 48.3182 | |
| After the intervention | 45.52941 ± 1.809122 | 41.84872 |
4.5. Relationship Between Fatigue, Dyspnea and Anxiety with Confounding Variables by Multiple Linear Regression Test
Multiple linear regression analysis examined the effects of reflexology on dyspnea, fatigue, and anxiety while controlling for confounding variables. The results showed a significant reduction in state anxiety by 18 units and trait anxiety by 13.75 units in the intervention group (P < 0.05). Dyspnea also decreased significantly by 2.4 units (P < 0.05). Although fatigue was 59% lower in the intervention group than in the control group, this difference was not statistically significant (P > 0.05). No significant changes were observed in the control group for anxiety, dyspnea, or fatigue (P > 0.05) (Table 5).
Table 5.Relationship Between Fatigue, Dyspnea and Anxiety with Confounding Variables by Multiple Linear Regression Test
| Variables | Odds Ratio | SE | z | P > z | Confidence Interval (95%) | Interval |
|---|---|---|---|---|---|---|
| Fatigue (intervention group) | ||||||
| After intervention | 0.4163874 | 0.3252505 | -1.12 | 0.262 | 0.0900748 | 1.924829 |
| Gender (female) | 0.6901259 | 0.7833979 | -0.33 | 0.744 | 0.0745908 | 6.385157 |
| Education | ||||||
| Under diploma | 0.3749825 | 0.417209 | -0.88 | 0.378 | 0.04236 | 3.319447 |
| Diploma and higher | 0.8442963 | 0.7686895 | -0.19 | 0.853 | 0.1417485 | 5.02888 |
| Economic status (moderate) | 1.331125 | 1.60828 | 0.24 | 0.813 | 0.1246776 | 14.21181 |
| Severity (moderate) | 1.24121 | 1.306359 | 0.21 | 0.837 | 0.1577484 | 9.766195 |
| Cons | 11.14933 | 29.65811 | 0.91 | 0.365 | 0.0606716 | 2048.862 |
| Fatigue (control group) | ||||||
| After intervention | 1.520504 | 1.401723 | 0.45 | 0.649 | 0.2496212 | 9.261762 |
| Gender (female) | 1.785532 | 2.306334 | 0.45 | 0.654 | 0.1420001 | 22.45157 |
| Education | ||||||
| Under diploma | 0.0838451 | 0.1262228 | -1.65 | 0.100 | 0.0043859 | 1.602877 |
| Diploma and higher | 0.2700703 | 0.4093585 | -0.86 | 0.388 | 0.0138443 | 5.268458 |
| Economic status (moderate) | 7.807444 | 13.48095 | 1.19 | 0.234 | 0.2647017 | 230.2825 |
| Severity (moderate) | 0.9749052 | 1.447062 | -0.02 | 0.986 | 0.0531514 | 17.88174 |
| Cons | 0.9867094 | 4.743248 | -0.00 | 0.998 | 0.0000799 | 12190.8 |
| Dyspnea (intervention group) | ||||||
| After intervention | -2.411765 | 0.4788656 | -5.04 | 0.000 | -3.389739 | -1.433791 |
| Gender (female) | 0.243229 | 0.6496193 | 0.37 | 0.711 | -1.083471 | 1.569929 |
| Age | 0.0214143 | 0.0171232 | 1.25 | 0.221 | -.013556 | .0563846 |
| Cons | 5.975351 | 1.880246 | 3.18 | 0.003 | 2.135376 | 9.815325 |
| Dyspnea (control group) | ||||||
| After intervention | -0.2352941 | 0.4964469 | -0.47 | 0.639 | -1.249174 | 0.7785856 |
| Gender (female) | 0.243229 | 0.6496193 | 0.37 | 0.711 | -1.083471 | 1.569929 |
| Age | 0.0214143 | 0.0171232 | 1.25 | 0.221 | -0.013556 | 0.0563846 |
| Cons | 5.975351 | 1.880246 | 3.18 | 0.003 | 2.135376 | 9.815325 |
| Manifest anxiety (intervention group) | ||||||
| After intervention | -18.16122 | 3.911156 | 4.64 | 0.000 | -9.975075 | -26.34736 |
| Gender (female) | 5.550546 | 4.224383 | 1.31 | 0.205 | -3.29119 | 14.39228 |
| Age | 0.0497863 | 0.1665574 | 0.30 | 0.768 | -0.2988223 | 0.3983948 |
| Severity (moderate) | 0.3513172 | 3.90109 | 0.09 | 0.929 | -7.813759 | 8.516393 |
| Education | ||||||
| Under diploma | 8.9175 | 5.528558 | 1.61 | 0.123 | -2.653905 | 20.48891 |
| Diploma and higher | 11.06385 | 5.169791 | 2.14 | 0.046 | 0.2433503 | 21.88434 |
| Cons | 2.709734 | 22.88392 | 0.12 | 0.907 | -45.18685 | 50.60632 |
| Manifest anxiety (control group) | ||||||
| After intervention | -2.650652 | 2.800325 | -0.95 | 0.355 | -8.492027 | 3.190723 |
| Gender (female) | 1.587219 | 4.386119 | 0.36 | 0.721 | -7.562064 | 10.7365 |
| Age | -0.0222838 | 0.2585986 | -0.09 | 0.932 | -0.5617111 | 0.5171436 |
| Severity (moderate) | -1.805716 | 5.520662 | -0.33 | 0.747 | -13.32162 | 9.710184 |
| Education | ||||||
| Under diploma | -7.686964 | 4.573678 | -1.68 | 0.108 | -17.22749 | 1.853561 |
| Diploma and higher | -6.473097 | 6.47071 | -1.00 | 0.329 | -19.97076 | 7.024567 |
| Cons | 38.79996 | 20.71836 | 1.87 | 0.076 | -4.417781 | 82.01769 |
| Hidden anxiety (intervention group) | ||||||
| After intervention | -13.76471 | 2.292615 | 6.00 | 0.000 | -9.082562 | -18.44685 |
| Gender (female) | -0.0697478 | 3.110114 | -0.02 | 0.982 | -6.421448 | 6.281952 |
| Age | -0.1067062 | 0.081979 | -1.30 | 0.203 | -.2741297 | 0.0607174 |
| Cons | 35.89416 | 9.001856 | 3.99 | 0.000 | 17.50992 | 54.2784 |
| Hidden anxiety (control group) | ||||||
| After intervention | -1.588235 | 2.881133 | -0.55 | 0.586 | -7.472294 | 4.295823 |
| Gender (female) | 0.8150178 | 2.912204 | 0.28 | 0.782 | -5.132495 | 6.762531 |
| Age | 0.0861672 | 0.1326778 | 0.65 | 0.521 | -0.1847971 | 0.3571315 |
| Cons | 42.095 | 9.017355 | 4.67 | 0.000 | 23.6791 | 60.51089 |
5. Discussion
The findings of this study demonstrated a significant reduction in dyspnea severity exclusively in the intervention group. These results align with the study by Sarikhani et al., which reported that foot reflexology improved asthma symptoms in the intervention group by increasing oxygen saturation and reducing breathing rates (16). Similarly, Jamali Soltani et al. found that foot reflexology was significantly effective in improving physiological responses, thereby alleviating respiratory distress in premature infants (17).
In the current study, after adjusting for potential confounders, the paired t-tests and multiple regression models also showed a statistically significant reduction in both state and trait anxiety levels in the intervention group. No such changes were observed in the control group. These findings are consistent with the study by Ren et al., which assessed anxiety levels in patients prior to cervical spine surgery. In their study, 10-minute massages with sweet almond oil, performed every other day for four weeks, led to a significant reduction in anxiety scores (18). Fritz and Paholsky further emphasized that foot stimulation activates the parasympathetic nervous system and downregulates stress hormones, contributing to anxiety reduction (19).
However, Gunnarsdottir and Jonsdottir found somewhat contradictory results when investigating the effect of foot reflexology on anxiety in patients undergoing vascular graft surgery. Their findings indicated only a slight reduction in anxiety scores following the intervention (20). This discrepancy could be attributed to the long interval between the reflexology sessions and the start of surgery, as well as the lack of control over potential confounders such as the use of anti-anxiety medications or other complementary therapies.
In addition to improvements in dyspnea and anxiety, this study found a significant reduction in fatigue levels among chronic respiratory disease patients in the intervention group compared to the control group. This finding is supported by Sajadi et al., who demonstrated that four weeks of foot reflexology massage (twice a week, 30 - 40 minutes per session) significantly reduced fatigue levels in patients with multiple sclerosis (21).
5.1. Limitations
This study had several limitations, including a small sample size that reduced generalizability. Changes in patient conditions, ICU admissions, mortality, early discharge, and poor adherence further decreased participation. These challenges highlight the difficulties of conducting clinical trials with critically ill patients. Future studies should use larger samples, include a wider range of CRDs, and implement strategies to improve adherence and reduce attrition for more reliable results.
5.2. Conclusions
This study found that foot reflexology significantly alleviates dyspnea, anxiety, and fatigue in patients with CRDs. These results highlight its potential as a complementary therapy alongside conventional treatments. Given similar findings in other studies, reflexology may also help manage these symptoms in other chronic conditions. Further research is needed to assess its long-term effects and broader clinical applications.
