S Andersen, N Hodgson
complementary therapy, dementia, long term care, reflexology
S Andersen, N Hodgson. Reflexology with Nursing Home Residents: A Case Vignette. The Internet Journal of Geriatrics and Gerontology. 2006 Volume 3 Number 2.
Complementary “touch” therapies such as massage and reflexology may help to reduce the experience of distress for nursing home residents by promoting a relaxation response. This paper discusses the use of reflexology as a clinical intervention in nursing home residents with mild to moderate dementia. A review of the literature indicates that reflexology is a useful tool in promoting relaxation and improving well-being. Referral criteria for reflexology in this population are suggested. We present the story of a resident whose primary diagnoses of moderate dementia, chronic obstructive pulmonary disease and depression is similar to the clinical presentation of many nursing home residents. The case illustrates the role of reflexology in assisting with the management of stress in residents with complex needs. Reflexology provides a holistic practice tool that does not rely on language, is minimally invasive, and can evoke a positive emotional response with little risk of adverse effect.
Source of support: The Farber Family Foundation
Reflexology is based on ancient principles and ideas that date back thousands of years (Crane 1997). It has been described as a unique method of using the thumb and fingers on reflex areas in the feet and hands that correspond to all of the glands, organs and parts of the body to elicit areas of potential or actual disorder (Byers, 1983; Crane, 1997). Reflexology charts depict the feet with diagrams of reflex points corresponding internal organs or parts of the body. Pressure applied to the reflex points is considered to promote better blood flow and nerve impulses, release toxins and endorphins and harmonize physiological function (Kuhn, 1999). Reflexology has also been described as a holistic healing technique that treats the individual as an entity, incorporating body, mind and spirit but does not diagnose or prescribe a cure (Dougans, 1996).
As a Complementary Alternative Medicine (CAM), it is not uncommon to find reflexology offered along side chiropractic techniques, acupuncture, and in conjunction with allopathic medicine. Practitioners can be found providing treatments in Asia, Australia, Europe, Canada, and the United States. Although techniques and educational training may vary throughout the world, practitioners collectively believe that healthy benefits can be achieved by stimulating the designated reflex points. Reflexologists advocate that this stimulation can help to relieve pain, increase blood and lymphatic flow and induce the relaxation response, with the ultimate goal of bringing the body back to a state of homeostasis or balance (Crane, 1997). Hands serve as acceptable substitutes when it is not possible to work with lower extremities (Byers, 1983).
As CAM therapies become more favorable, research to determine the usefulness and effectiveness of reflexology is taking priority (Mackereth et al., 2000; Richardson, 2000). Studies evaluating the effect of reflexology in a variety of health conditions have shown that it is a promising treatment in reducing pain and in promoting well being with little risk of side effects.
In randomized controlled trials, reflexology has been found to be effective in reducing pain in women with severe premenstrual symptoms (Oleson and Flocco, 1993), and in patients with migraine and tension headaches (Launso, Brendstrup and Arnberg, 1999). It has also demonstrated benefit in alleviating motor; sensory and urinary symptoms in patients with multiple sclerosis (Siev-Ner, et al., 2003). Recent systematic reviews on the efficacy of reflexology with cancer patients found positive improvements in anxiety and pain (Solà et al., 2003; Wilkinson et al, 2004). Although most of these findings are encouraging, several small studies found no significant reductions in improvements resulting from reflexology in patients recovering from knee surgery (Evans et al., 1998) and irritable bowel syndrome (Tovey, 2002).
Most studies of complementary treatments in nursing home residents are inconclusive and characterized by methodological deficiencies such as small sample size and inadequate controls (Diamond et al., 2003). However, the results from the clinical trials and systematic reviews described above offer support to the use of reflexology as a potentially useful intervention in the care of nursing home residents with unmet clinical needs.
Common Challenges in the Nursing Home
Challenges that may be encountered when doing reflexology include the state of the resident's health, participatory level and familiarity of therapeutic foot massage. Those residents having lack of knowledge for alternative therapies may be more likely to suspect or refuse the intervention while those who have had some form of therapeutic massage in the past or knew someone who had it may be more accepting and supportive. Conflicts with resident's schedules also may present a challenge.
When integrating reflexology in a resident's care plan, it is imperative for practitioners to know the health status of those who receive reflexology. Foot injury, phlebitis, kidney stones or gallstones, thrombosis and the presence of a pacemaker are all conditions that should be closely monitored when determining the length and depth of a treatment. Modifications may be needed for residents with these or other conditions such as arthritis, dermatitis or infections and for those who had difficulty sitting or laying in the traditional position for receiving a treatment (i.e. sitting in a wheelchair vs. a reclining chair). Knowing one's health history is an ethical responsibility that the practitioner must take seriously when determining the appropriateness of a treatment (Crane, 1997). In the case presented here, the participant's health history was carefully examined and approval was given by the staff medical doctor.
This story, which is presented by the reflexologist, is based on a true account of a resident, who along with her family agreed to receive reflexology. Prior to the intervention, the resident received literature about the treatments explaining the details and duration. It was verbally communicated to her that the sessions would take place once/week for four weeks. The reflexologist also spent time with the resident to discuss any questions or concerns.
When the reflexologist visited her for the first time, Mrs. A wore an expression of nervousness on her face. After all, a stranger had entered her sanctuary, a private space appointed with these simple furnishings: one twin bed, a stylish wooden end table with attached lamp, midsize bureau, and a soft-clothed blue recliner and ottoman. An abundance of family pictures, some pinned on a cork-like bulletin board and others decoratively framed sat on her large window sill, each one telling the story of her life before she came to know the nursing home as her residence. Pretty palates of muted pink, yellow, blue and peach created the décor for the matching bedspread, valence and wallpaper border. Metallic-looking crumpled candy wrappers, along with unopened packs of chocolate bars, crunchy snacks and cans of cola hinted that she had a sweet tooth and enjoyed the treats her family brought her each week.
After a few moments of the reflexologist reiterating the purpose and legitimacy of the visits, Mrs. A bashfully removed her socks and shoes and propped her feet on the ottoman. With a look of curiosity in her eyes, Mrs. A watched as the reflexologist massaged her feet and gently stretched each toe, being mindful of any discomfort the resident may have felt by asking how it felt. Using specific techniques and a treatment sequence tailored for the study, each region of Mrs. A's foot was addressed with careful attention, first with the right and then the left, for a total of thirty minutes. When she coughed several times during the treatment, a cough that caused her eyes to squint and body to scrunch, Mrs. A briefly explained it was a result of her chronic health condition. This condition appeared to make her uncomfortable, sad and even a little withdrawn. She focused on the outside, staring at the trees and landscape.
By the 2 nd week of the visit, it seemed as though there was a bright gleam in Mrs. A's eyes when the reflexologist entered the room. With her bare feet ready-and-waiting on the ottoman, Mrs. A softly whispered, “hello” and offered a piece of chocolate. There was a change in the air since the last visit. Mrs. A's spirit was more uplifting and she was communicative. She shared information about her family and the excitement she was feeling for the birth of her first great-grandchild. At one point during the treatment, the reflexologist observed her falling asleep, looking peaceful and relaxed. The reflexologist was very observant for any of the common occurrences like, sweaty palms, coughing, twitching or tingling in arm or leg, warmth or feeling of movement in corresponding area being worked on, fatigue and disappearance of pain or discomfort. This occurrence may be the result of the body flushing out toxins that have built up over time and considered to be a normal reaction of the body's attempt to achieve balance (Crane, 1997). As the session wrapped up, Mrs. A expressed a sincere “thank you” and asked when the next visit would be.
The final weeks of the treatment mirrored week two. By this time, a level of comfort and routine had been established between Mrs. A and the reflexologist. Each week the reflexologist visited Mrs. A, she made notations on the form including any conversation that took place, verbal feedback in response to the treatment and any body language displayed. The information was used to compare and contrast each of the visits and was put in a folder designated for Mrs. A and filed confidentially. Improvements in recognition recall of the intervention increased over the course of the visits. Mrs. A provided the key ingredient to a meaningful treatment by voicing which areas of her feet were bothersome when pressure was applied. This enabled the reflexologist to evaluate areas of concern. Other feedback like, “feels nice” and “this is soothing” offered a sense of understanding for how Mrs. A benefited from the treatments.
It has been quite some time since Mrs. A received reflexology and when the reflexologist sees her, it is usually in passing. During one particular encounter, the reflexologist approached Mrs. A and greeted her with a hug. It was assumed that because about a month passed after the intervention, Mrs. A most likely wouldn't remember her and may have been put off by the physical contact. It was when Mrs. A took her hand that the reflexologist realized she had not been forgotten. Holding the reflexologist's hand with hers, Mrs. A looked up and voiced, “How are you doing? I miss your visits.”
The four sessions of reflexology showed a reduction in observant stress. The sessions were administered with ease and no adverse reactions were observed or reported. Whether it was the result of the treatments, steady visits, or both, one thing is evident; Mrs. A was able to remember the reflexologist and make an association when they saw each other. It is not known how long Mrs. A will be able to reflect on the reflexology experience. But what is known is that there was a definite change in Mrs. A's mood when the treatments were taking place. This effect, if nothing else, is reassuring toward achieving the goal of improving the quality of life for Mrs. A and other nursing home residents.
Long term care providers interested in incorporating reflexology into their practice can obtain training and certification to ensure proper administration of reflexology techniques. In the United States, there are regulations for practicing reflexology with each state having its' own set of education requirements. For more information on state requirements, see http://www.reflexology-research.com/LAWS_1.html (Kunz & Kunz, 2004b).