Comparing the Effects of Warm Footbath and Foot Reflexology on the Fatigue of Patients Undergoing Radiotherapy: A Randomized Clinical Trial

Abstract

Background and Aim:

Fatigue is a common side effect of radiotherapy. While warm footbath and foot reflexology can both reduce fatigue, it is still unclear which method is more effective in reducing fatigue. This study aimed to compare the effects of warm footbath and foot reflexology on the fatigue of patients undergoing radiotherapy.

Method:

A randomized clinical trial study was conducted on 62 patients undergoing radiotherapy. Eligible patients were randomly assigned to the 2 groups. Patients in the footbath group immersed their feet in 41°C water for 20 minutes every night for 2 weeks starting from the seventh day of radiotherapy. Patients in the reflexology group received 20 minutes of foot reflexology every night for 2 weeks starting from the seventh day of radiotherapy. Fatigue was measured by the Multidimensional Fatigue Inventory (MFI) once on the seventh day of radiotherapy and 3 more times on days 7, 14, and 28 after the start of the intervention. Data were analyzed by SPSS20 and descriptive/inferential statistics.

Results:

The total MFI score of both groups declined significantly over time (P < .001). The reflexology group indicated a significant reduction from 90.9 ± 3.2 in the pre-test to 56.0 ± 3.7 on the 28th day in, while the footbath group indicated it from 90 ± 2.6 in the pre-test to 71.4 ± 2.8 on the 28th day.

Conclusion:

Our results showed that foot reflexology and warm footbath reduced the fatigue of patients undergoing radiotherapy. However, foot reflexology was more effective in reducing the fatigue of patients undergoing radiotherapy than warm footbath. It is recommended that simple and low cost non-pharmacological interventions such as foot reflexology to decrease of side effect of radiotherapy among cancer patients should be widely performed.

Trial registration: Iranian Registry of Clinical Trials (IRCT20190625044009N1).

Keywords

reflexology footbath fatigue radiotherapy

Introduction

According to a 2019 report published by the World Health Organization (WHO), cancer was a leading cause of death before the age of 70 in 112 out of 183 countries studied, and ranked third or fourth in 23 other countries.¹ Roughly 52% of all cancer patients undergo radiotherapy during their treatment course.² Radiotherapy involves using gamma rays, X-rays, or accelerated particles to destroy cancer cells³ and delivers the appropriate amount of radiation for damaging the cancerous tissue while protecting the surrounding healthy tissues.⁴

Cancer Related Fatigue (CRF), one of the most common side effects of cancer, differs from other types of fatigue in intensity and persistence, and rest and sleep are ineffective on it. Roughly 65% of all cancer patients experience Cancer Related Fatigue, with the rate reaching to 80%-90% among those undergoing radiotherapy.⁵

Pharmaceutical and non-pharmacological treatments apply to Cancer Related Fatigue,⁶ but Mustian et al indicated⁶ that pharmaceutical treatments were less effective than non-pharmacological (exercise and psychological) interventions.⁷ Patients themselves must practice many non-pharmacological methods to improve their autonomy.^8-10 Non-pharmacological methods have fewer side effects and negative consequences than pharmacological treatments^11,12; the most widely used non-pharmacological methods are hydrotherapy, biofeedback, aromatherapy, meditation, massage, and acupuncture.^13,14

People usually use hydrotherapy for their relaxation and protection of their health.¹⁵ Warm footbath, one form of hydrotherapy, involves immersing the feet in water at a temperature of 40°C to 43°C for 10 to 30 minutes,¹⁶ expands the foot vessels to increase blood circulation and timely brings oxygen and nutrients to the brain that are needed to relieve fatigue.¹⁷ Sharma et al found that footbath with warm water reduced the fatigue of cancer patients undergoing radiotherapy.¹⁸

Massage is another non-pharmacological intervention for fatigue alleviation.¹³ Foot reflexology involves applying pressure by fingers, especially the thumb, on certain reflex points in the feet. Reflexologists argue that applying pressure on these reflex points can affect the physiological responses of certain organs.¹⁹ This therapy increases patient comfort by inducing physiological changes; pressure on the reflexive areas stimulates hundreds of nerve endings in the soles, releases endorphins and consequently prevents pain transfer, causes comfort, decreases tension, and increases tranquility.²⁰ Tarrasch et al reported that foot reflexology reduced the fatigue of patients with breast cancer during adjuvant radiation therapy.²¹

Although both warm footbath and foot reflexology are effective in reducing patient’s fatigue, to the best of our knowledge, no study compared the effects of these two interventions on the fatigue of patients undergoing radiotherapy. Therfore, This study aimed to compare the effects of warm footbath and foot reflexology on the fatigue of patients undergoing radiotherapy.

Material and Methods

Study Design and Participants

This randomized clinical trial study was conducted in Mashhad University of Medical Sciences (Mashhad, Iran) in 2019. The study protocol followed the CONSORT criteria as shown in Figure 1. The subjects were recruited among cancer patients undergoing radiotherapy, who stayed in the guest house affiliated to Reza Oncology and Radiotherapy Center, Mashhad, Iran (Figure 1).

Figure 1.

CONSORT diagram for study.

Inclusion and Exclusion Criteria

The inclusion criteria were conscious patients with non-metastatic cancer aged 18 to 60 years, who scored at least 30 points from the Multidimensional Fatigue Inventory (MFI) questionnaire, had a 28-day radiotherapy course, had contact number for follow-up and stayed in the guest house at Reza Oncology and Radiotherapy Center. The exclusion criteria were patients with peripheral vascular thrombosis; Berger’s disease; diabetes; wound or infection in the foot area; decreased peripheral sensation; neurologic conditions due to foot spasms when immersed in water; for example patients with multiple sclerosis who underwent chemotherapy at the same time; the occurrence of a major stressful event; exacerbation of the disease that required special care; postponement of radiotherapy; metastasis confirmed by diagnostic tests; and changes in treatment protocols.

Sample Size

The sample size was estimated based on the results of similar studies using comparison of means, 95% confidence and 80% test power, so the sample size was calculated to be 29 per group, but ultimately 34 patients were recruited into each group to account for possible dropout rate. Four participants in the footbath group left the study because of exacerbation of their disease and 2 in the reflexology group left the study because of the postponement of radiotherapy, so 62 people, 30 in the footbath group and 32 in the reflexology group, remained in the study (Figure 1).

Randomization

Eligible patients were randomly allocated to the footbath and reflexology groups through drawing random sequences (generated by a randomization website).

Outcome Measures

The primary outcome was the cancer patients’ fatigue which was assessed using the Multidimensional Fatigue Inventory (MFI) scale. A demographic questionnaire was used to collect information about demographic characteristics and disease history of patients (age, gender, marital status, and type of cancer). Since the demographic questionnaire and the informed consent form consisted of clear straight forward questions frequently used in research, this questionnaire was completed with the data collected during interviews or from the medical files of patients. The Multidimensional Fatigue Inventory (MFI) measures fatigue with 20 items in 5 dimensions: General Fatigue (4 items), Physical Fatigue (4 items), Reduced Activity (4 items), Reduced Motivation (4 items), and Mental Fatigue (4 items).²² The items of the MFI are scored on a 5-point Likert scale from 1 (=yes, it is true) to 5 (=no, it is not true), with items 2, 5, 9, 10, 13, 14, 16, 17, 18, 19 rated in reverse. The total score of each dimension ranges from 4 to 20. The total MFI score, obtained by summing the scores of its 5 dimensions, ranges from 20 to 100, with higher scores indicating more fatigue.²² The validity and reliability of the Persian version of the Modified Fatigue Impact Scale (MFIS) questionnaire for Iranian patients previously was done in study by Ghajarzadeh et al.²³ In our study the validity of the Persian version of MFI were reassessed and approved using content validity by 10 faculty members of Mashhad University of Medical Sciences. They had PhD degrees in nursing and were experts in the field of education and care of cancer patients undergoing radiotherapy, as well as specialists in complementary medicine for cancer patients. In our study the reliability of the Persian version of MFI was calculated to be 0.86 by test-retest with 10 people. Patients completed MFI on the seventh day of radiotherapy (as pre-test) and the 7th, 14th, and 28th days after the start of the intervention (as post-test).

Footbath Group

The patients in footbath group immersed their feet up to 10 cm into water inside a 40 × 27 × 45 cm plastic container (Limon brand, model 3 made in Iran) at a temperature of 41°C to 42°C for 20 minutes every night 1 hour before the usual bedtime²⁴ (between 21:00 and 22:00) starting from the seventh day of radiotherapy, for 2 weeks.¹³ The water temperature was measured by the researcher with a thermometer (TROTEC brand, model BT20 made in Germany).

Reflexology Group

The patients in foot reflexology group were massaged with olive oil (Ghonche brand, refined model made in Iran) for 20 minutes (10 minutes each foot) every night starting from the seventh day of radiotherapy for 2 weeks. Reflexology was performed under supervision of complementary medicine consultan by a researcher who received a certificate after completing 30-hour theoretical and practical training. The researcher massaged the area connected to the first metatarsal bone and the solar plexus and the areas connected to the toe, pituitary and pineal glands. Each foot was massaged for 10 minutes (1 minute of general foot massage and then 3 minutes of massage for each area). Five basic massage techniques were used: effleurage (circular stroking movements), petrissage (kneading movements), friction (rubbing strokes), vibration (shaking movements to loosen the body), and tapotement (tapping). Creating pressure in the reflex areas of the foot during illness leads to the breaking of calcium and uric acid crystals accumulated in the nerve terminals and it releases blocked energy pathways throughout the body; it also improves blood flow throughout the body.²⁵ The applied pressure was kept at 4 to 5 kg by asking the researcher to calibrate the hand pressure with a digital scale every night before the intervention. The researcher sat on a chair at the bottom of the bed and asked the patient to lie in the supine position to have full access to the soles of both feet. The researcher removed all hand accessories (watches, rings, bracelets, etc.) and trimmed her nails.

Data Collection

Before sampling, permission was obtained from the research ethics committee of Mashhad University of Medical Sciences (IR.MUMS.NURSE.REC.1398.022). To start sampling, we submitted an official letter of introduction issued by the School of Nursing and Midwifery of Mashhad University of Medical Sciences to Reza Radiotherapy and Oncology Center. After gaining permission and coordinating with the center’s head and matron, and head of the guest house, the researcher attended the guest house to recruit interested patients.

Data Analysis

Statistical analyses were performed using SPSS20 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp); descriptive statistics (frequency distribution, mean, standard deviation) were used to describe and summarize data, while inferential statistics, including chi-square test, exact chi square, independent t-test, Mann-Whitney test, and repeated-measures ANOVA were used to test the hypothesis. The normality of quantitative variables was checked by Kolmogorov-Smirnov and Shapiro-Wilk tests. All statistical tests were conducted at a confidence level of 95% and a significance level of P < .05.

Results

Patients’ Demographic Characteristics

The mean ages of patients in the reflexology and footbath groups were 44.3 ± 10.9 and 46.9 ± 9.5 years, respectively. Fifty-nine point four percent of patients (N = 19) in the reflexology group and 46.7% (14 people) of patients in the footbath group were women. Statistical tests showed that the 2 groups were homogeneous in terms of age, gender, marital status, and type of cancer (P < .05) (Table 1).

Table 1.

Sociodemographic Characteristics of the Patients.

Characteristics		Group		P value
Characteristics		Reflexology	Footbath	P value
Average Age (year)		X ± SD	X ± SD	P = .327*
		44.34 ± 10.91	46.93 ± 9.51
		N (%)	N (%)
Gender	Male	13 (40.6)	16 (53.3)	P = .316**
Gender	Female	19 (59.4)	14 (46.7)	P = .316**
Marital Status	Single	10 (31.2)	8 (26.7)	P = .846***
Marital Status	Married	22 (68.8)	22 (73.3)	P = .846***
Type of cancer	Breast	13 (40.6)	7 (23.3)	P = .752***
	Lung	7 (21.9)	8 (26.7)
	Digestive system	9 (28.2)	13 (43.3)
	Bladder	2 (6.3)	2 (6.7)
	Gynecologic	1 (3.1)	0 (0.0)

Independent t-test. **Chi-square. ***Exact chi-square.

Primary Outcomes

As shown in Table 2, we found no significant difference in the total MFI score or the scores of its dimensions between the 2 groups at the pre-test stage (P < .05), but all of these scores were significantly lower in the reflexology group than in the footbath group at the post-test stage (P < .05), except for the score of the Reduced Activity dimension on day 7. The total MFI score and the scores of its dimensions significantly decreased in both groups from pre-test to post-test. The repeated-measures ANOVA showed a significant reduction in the total MFI score and the scores of its dimensions in both groups over time (from before the intervention to 7, 14, and 28 days after the intervention), with the reduction being more pronounced in the reflexology group (P < .001), suggesting that reflexology was more effective in reducing fatigue than footbath (Table 2).

Table 2.

Intragroup and Intergroup Comparisons of the Patients’ Fatigue Score Averages.

Fatigue	TimeGroup	Before	Day 7	Day 14	Day 28	P value**
Fatigue	TimeGroup	Before	Day 7	Day 14	Day 28	Time	Group	Time-Group
Total score	Reflexology	90.9 ± 3.2	87.0 ± 2.3	72.2 ± 2.7	56.0 ± 3.7	P < .001	P < .001	P < .001
	Footbath	90.0 ± 2.6	91.0 ± 2.4	80.6 ± 3.2	71.4 ± 2.6
	P value*	P = .223	P < .001	P < .001	P < .001
General fatigue	Reflexology	18.2 ± 1.0	17.9 ± 0.7	14.3 ± 1.4	11.0 ± 1.6	P < .001	P < .001	P < .001
	Footbath	18.1 ± 0.7	18.4 ± 0.9	16.1 ± 1.4	14.7 ± 1.2
	P value*	P = .711	P = .033	P < .001	P < .001
Physical fatigue	Reflexology	18.6 ± 1.2	17.9 ± 0.8	14.9 ± 1.5	11.5 ± 1.8	P < .001	P < .001	P < .001
	Footbath	18.0 ± 0.9	18.5 ± 1.1	16.9 ± 1.2	14.1 ± 1.5
	P value*	P = .048	P = .024	P < .001	P < .001
Reduced activity	Reflexology	19.0 ± 1.0	18.2 ± 1.0	16.1 ± 0.9	12.9 ± 1.5	P < .001	P < .001	P < .001
	Footbath	18.5 ± 0.8	18.5 ± 0.7	18.0 ± 1.0	15.6 ± 1.5
	P value*	P = .070	P = .183	P < .001	P < .001
Reduced motivation	Reflexology	16.9 ± 1.2	16.0 ± 1.1	12.9 ± 1.9	10.1 ± 1.1	P < .001	P < .001	P < .001
	Footbath	16.9 ± 1.7	17.0 ± 1.3	14.0 ± 1.9	13.5 ± 1.2
	P value*	P = .940	P = .003	P = .028	P < .001
Mental fatigue	Reflexology	18.1 ± 1.0	17.7 ± 1.4	13.8 ± 1.9	10.4 ± 1.7	P < .001	P < .001	P < .001
	Footbath	18.3 ± 0.8	18.4 ± 1.0	15.4 ± 1.1	13.4 ± 1.4
	P value*	P = .383	P = .036	P < .001	P < .001

Independent t-test. **Repeated-measures ANOVA.

Discussion

This study aimed to compare the effects of warm footbath and foot reflexology on the fatigue of patients undergoing radiotherapy. The pre-test measurement showed that patients in both groups experienced a high level of fatigue, while the post-test measurement showed that both interventions could alleviate the fatigue of these patients. We found that foot reflexology was more effective in reducing fatigue than warm footbath. Since this is the first study to compare the effects of warm footbath and foot reflexology on the fatigue of patients undergoing radiotherapy, we discuss our results alongside the findings of related studies in the field.

We indicated a 38-point reduction in the fatigue of patients 28 days after foot reflexology (compared to the pre-test). Tarrasch et al found that reflexology reduced the fatigue of patients with breast cancer undergoing radiotherapy²¹; Dikmen and Terzioglu reported that reflexology reduced the fatigue of women with gynecological cancer undergoing chemotherapy.²⁶ Rambod et al showed the positive impact of foot reflexology on fatigue of patients with lymphoma.²⁷ There are studies of the positive impact of reflexology on the fatigue of patients suffering from other diseases; Unal²⁸ and Polat and Ergüney²⁹ reported fatigue alleviation following reflexology in patients under hemodialysis and patients with COPD. It is believed that reflexology triggers endorphin release, induces a feeling of relaxation and well-being, improves blood flow and endothelial function,³⁰ and reduces stress and anxiety.²⁷ Therefore, it is reasonable to argue that reflexology can reduce the fatigue of cancer patients by improving their blood circulation and reducing their stress and anxiety.

In this study, patients in the warm footbath group experienced a 21-percent fatigue reduction 28 days after this intervention (compared to the pre-test). Sharma et al found that warm footbath reduced the fatigue of cancer patients undergoing radiotherapy,¹⁸ while Shafeik et al reported that footbath reduced the fatigue of patients under hemodialysis.¹⁷ Son and Yoo³¹ and Choi and Song³² reported the positive effect of warm footbath on fatigue of patients with a stroke and postpartum women, respectively.

Conclusion

Our results showed that foot reflexology and warm footbath reduced the fatigue of patients undergoing radiotherapy. Comparing the mean (SD) fatigue scores indicated that foot reflexology was more effective on fatigue alleviation for these patients. Fatigue is one of the most common complaints of patients undergoing radiotherapy and its implications can directly affect a patient’s life style and quality of life, so we recommend the independent or combined use of foot reflexology and warm footbath to reduce fatigue in cancer patients undergoing radiotherapy. This study had several limitations: the sample size was small; which makes it difficult to generalize results to all patients. We conducted this study only on cancer patients undergoing radiotherapy, so the results can only be generalizable to this group of patients. We were unable to control other factors that might have influenced patients’ fatigue.

Footnotes

Acknowledgements

The author would like to thank the head of Reza Radiotherapy and Oncology Center, the head of the guest house, the project’s educational supervisor, and all patients for their sincere contributions and cooperation.

Author Contributions

MR prepared the writing of the initial draft, acquisition of data; SRM obtained funding for the manuscript, analyzed and interpreted the data, and conceptualized the paper. SM reviewed and synthesized the literature. HBT and MN supervised, proofread, and provided intellectual support in terms of statistical analysis and administrative, technical, and material support and supervised the preparation of the manuscript. All authors read and approved the final manuscript

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We received financial support from the vice chancellor for research of Mashhad University of Medical Sciences.

Ethical Approval

The study was conducted after receiving approval from the regional research ethics committee with the code 971793, and registered in the Iranian Registry of Clinical Trials with the code IRCT20190625044009N1. An official permission was obtained from hospital administrators to conduct the study. The study purpose and importance were explained to participants, who met the inclusion criteria, and they signed the written consent form. Anonymity and confidentiality were assured through coding the data. Participants were assured that their participation was voluntary and they could withdraw from the study at any time without any penalty. All methods were performed in accordance with the relevant guidelines and regulations, which are aligned with the Declaration.

Guarantor

ORCID iD

Mahla Rajabzadeh

References

Perin

Mulick

Yeung

, et al. Global, regional, and national causes of under-5 mortality in 2000-19: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet Child Adolesc Health. 2022;6:106-115.

Delaney

Barton

MB.

Evidence-based estimates of the demand for radiotherapy. Clin Oncol. 2015;27:70-76.

Yang

Xing

Optimization of radiotherapy dose-time fractionation with consideration of tumor specific biology. Med Phys. 2005;32:3666-3677.

Washington

Leaver

DT.

Principles and Practice of Radiation Therapy-E-Book. Elsevier Health Sciences; 2015.

Fabi

Bhargava

Fatigoni

, et al. Cancer-related fatigue: ESMO clinical practice guidelines for diagnosis and treatment. Ann Oncol. 2020;31:713-723.

Hilfiker

Meichtry

Eicher

, et al. Exercise and other non-pharmaceutical interventions for cancer-related fatigue in patients during or after cancer treatment: a systematic review incorporating an indirect-comparisons meta-analysis. Br J Sports Med. 2018;52:651-658.

Mustian

Alfano

Heckler

, et al. Comparison of pharmaceutical, psychological, and exercise treatments for cancer-related fatigue: a meta-analysis. JAMA Oncol. 2017;3:961-968.

Haji Ali Beigloo

Mohajer

Eshraghi

, et al. Self-administered medications in cardiovascular ward: A study on patients’ self-efficacy, knowledge and satisfaction. Evidence Based Care 2019; 9: 16-25.

Sarboozi Hosein َAbadi

Namazi Nia

Mazlom

. Effect of self-determination theory-based discharge program on lifestyle and readmission of patients with heart failure: A clinical trial. Evidence Based Care 2020; 10: 25-35.

10.

Hajialibeigloo

Mazlum

Mohajer

, et al. Effect of self-administration of programme on cardiovascular inpatients’ medication adherence and nurses’ satisfaction: A randomized clinical trial. Nursing open 2021; 8: 1947.

11.

Zargarzadeh

Memarian

Assessing barriers for using of complementary medicine in relieving pain in patients by nurses. Quart J Nurs Manag. 2013;1(4):53-45.

12.

Nia

Mohajer

Bagheri

, et al. The effects of family-centered empowerment model on depression, anxiety, and stress of the family caregivers of patients with COVID-19: a randomized clinical trial. BMC Primary Care 2022; 23: 185.

13.

Bossola

Di Stasio

Antocicco

Pepe

Marzetti

Vulpio

. 1-year course of fatigue in patients on chronic hemodialysis. Int J Urol Nephrol. 2017;49:727-734.

14.

Ramezani Kermani

Aghebati

Mohajer

, et al. Effect of guided imagery along with breathing relaxation on sleep quality of the elderly patients under abdominal surgery: a randomized clinical trial. Holistic Nursing Practice 2020; 34: 334-344.

15.

Soumya

Effectiveness of footbath therapy on fatigue among patients with chronic renal failure in selected hospitals at Mangalore. Int J Sci Res. 2014;3:2277-8179.

16.

Xiao

L-J

Tao

Traditional Chinese medicine (TCM) therapy. Adv Exp Med Biol. 2017;1010:261-280.

17.

Shafeik

Abdelaziz

ElSharkawy

Effect of warm water foot bath on fatigue in patients undergoing hemodialysis. Int J Nurs Didactics. 2018;8:26-32.

18.

Sharma

Prakash

Priya

JPN

. Effectiveness of “Warm Footbath” on fatigue and insomnia in patients undergoing radiotherapy. Int J Nurs Educ Res. 2016;4:363-366.

19.

Iqbal

Reflexology: basic guide. Glob J Addict Rehabil Med. 2018;6:26-27.

20.

Pitman

MacKenzie

Reflexology: a practical approach. Nelson Thornes; 2002.

21.

Tarrasch

Carmel-Neiderman

Ben-Ami

, et al. The effect of reflexology on the pain-insomnia-fatigue disturbance cluster of breast cancer patients during adjuvant radiation therapy. J Altern Complement Med. 2018;24:62-68.

22.

Smets

Garssen

Bonke

De Haes

JC.

The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res. 1995;39:315-325.

23.

Ghajarzadeh

Jalilian

Eskandari

Ali Sahraian

Reza Azimi

Validity and reliability of Persian version of Modified Fatigue Impact Scale (MFIS) questionnaire in Iranian patients with multiple sclerosis. Disabil Rehabil. 2013;35:1509-1512.

24.

Yang

H-L

Chen

X-P

Lee

K-C

Fang

Chao

YF.

The effects of warm-water footbath on relieving fatigue and insomnia of the gynecologic cancer patients on chemotherapy. Cancer Nurs. 2010;33:454-460.

25.

Moghimi-Hanjani

Mehdizadeh-Tourzani

Shoghi

The effect of foot reflexology on anxiety, pain, and outcomes of the labor in primigravida women. Acta Med Iran. 2015;53:507-511.

26.

Dikmen

Terzioglu

Effects of reflexology and progressive muscle relaxation on pain, fatigue, and quality of life during chemotherapy in gynecologic cancer patients. Pain Manag Nurs. 2019;20:47-53.

27.

Rambod

Pasyar

Shamsadini

The effect of foot reflexology on fatigue, pain, and sleep quality in lymphoma patients: a clinical trial. Eur J Oncol Nurs. 2019;43:101678.

28.

Unal

Balci Akpinar

The effect of foot reflexology and back massage on hemodialysis patients' fatigue and sleep quality. Complement Ther Clin Pract. 2016;24:139-144.

29.

Polat

Ergüney

The effect of reflexology applied to patients with chronic obstructive pulmonary disease on dyspnea and fatigue. Rehabil Nurs. 2017;42(1):14-21.

30.

McCullough

JEM

Liddle

Sinclair

Hughes

. Reflexology: a randomised controlled trial investigating the effects on beta-endorphin, cortisol and pregnancy related stress. Complement Ther Clin Pract. 2018;31:76-84.

31.

Son

Yoo

MS.

Effects of a Footbath program on heart rate variability, blood pressure, body temperature and fatigue in stroke patients. J Korean Biol Nurs Sci. 2016;18:51-59.

32.

Choi

Song

Efficacy of a footbath for post-partum fatigue in South Korea: A quasi-experimental study. Jpn J Nurs Sci. 2017;14:126-134.