THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 00, Number 00, 2017, pp. 1–7

ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2017.0023

ORIGINAL ARTICLE

The Effect of Reflexology on the Pain-Insomnia-Fatigue

Disturbance Cluster of Breast Cancer Patients
During Adjuvant Radiation Therapy
Ricardo Tarrasch, PhD,1 Narin N. Carmel-Neiderman, MD,2 Sarah Ben-Ami, MSc,3
Bella Kaufman, MD,3 Raphi Pfeffer, MD,4 Merav Ben-David, MD,4,5 and Dorit Gamus, MD, PhD2

Abstract
Objective: To evaluate the effects of reflexology treatment on quality of life, sleep disturbances, and fatigue
in breast cancer patients during radiation therapy.
Methods/Subjects: A total of 72 women with breast cancer (stages 1–3) scheduled for radiation therapy were
recruited.
Design: Women were allocated upon their preference either to the group receiving reflexology treatments
once a week concurrently with radiotherapy and continued for 10 weeks or to the control group (usual care).
Outcome measures: The Lee Fatigue Scale, General Sleep Disturbance Scale, and Multidimensional Quality
of Life Scale Cancer were completed by each patient in both arms at the beginning of the radiation treatment,
after 5 weeks, and after 10 weeks of reflexology treatment.
Results: The final analysis included 58 women. The reflexology treated group demonstrated statisti-
cally significant lower levels of fatigue after 5 weeks of radiation therapy ( p < 0.001), compared to the
control group. It was also detected that although the quality of life in the control group deteriorated after
5 and 10 weeks of radiation therapy ( p < 0.01 and p < 0.05, respectively), it was preserved in the reflexology
group, which also demonstrated a significant improvement in the quality of sleep after 10 weeks of radia-
tion treatment ( p < 0.05). Similar patterns were obtained in the assessment of the pain levels experienced by
the patients.
Conclusions: The results of the present study indicate that reflexology may have a positive effect on fatigue,
quality of sleep, pain, and quality of life in breast cancer patients during radiation therapy. Reflexology
prevented the decline in quality of life and significantly ameliorated the fatigue and quality of sleep of these
patients. An encouraging trend was also noted in amelioration of pain levels.

Keywords: reflexology, radiation therapy, fatigue, breast cancer

Introduction 80% of the patients undergoing radiation treatment suf-

fer from fatigue,2 with a resultant decrease in quality of

C ancer-related fatigue (CRF) is one of the most

common side-effects among breast cancer patients dur-
ing adjuvant radiation treatment.1 It is estimated that about
life (QOL).
In addition to fatigue, patients undergoing radiotherapy
often experience poor sleep quality, which by itself might be

1
The Jaime and Joan Constantiner School of Education, Tel-Aviv University, Tel-Aviv, Israel.
2
Complementary and Integrative Medicine Service, Sheba Medical Center, Ramat-Gan, Israel.
3
Oncology Department, Sheba Medical Center, Ramat-Gan, Israel.
4
Radiation Oncology Department, Sheba Medical Center, Ramat-Gan, Israel.
5
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
This study was presented at: The International Congress on Integrative Medicine and Health (ICIMH), Las Vegas, Nevada,
May 17–20, 2016.

1
2 TARRASCH ET AL.
a risk factor for CRF. It has been reported that patients with
breast cancer experience sleep disturbance more frequently
and with a greater severity than patients with prostate can-
cer, although both populations report poor sleep quality and
fatigue.3
The pain-insomnia-fatigue symptom cluster is one of the
clusters (co-occurrence of symptoms) found in breast cancer
patients during radiation treatment4 and if not adequately
managed, may affect mood, role performance, social func-
tions, ability to tolerate and continue cancer therapies, and
overall QOL.5,6 It has been suggested therefore that these
symptoms should be addressed as part of comprehensive
cancer care.
While there are limited pharmacologic interventions for
CRF,7 several nonpharmacologic approaches have demon-
strated encouraging results such as exercise8,9 and psycho-
logic interventions.10
Complementary and alternative medicine (CAM) thera-
pies are gradually gaining more interest in cancer symptom
management.11 More than 50% of cancer patients in Israel
use complementary medicine.12 There is evidence for the
benefits of massage for symptom management of cancer
patients. A systematic review and meta-analysis that eval-
uated the effect of massage interventions on treatment-
related side-effects of breast cancer patients demonstrated
that regular use of massage led to significantly greater re-
ductions in anger and fatigue symptoms.13 A prospective
multicenter study of CAM utilization among breast cancer
patients during radiation treatment demonstrated that mas-
sage and reflexology comprised almost 40% of all CAM
practices.14 In another study 40.1% of the women treated for
primary breast cancer reported the use of CAM, reflexology
being the fifth most common method of treatment, and the
leading of the massage therapies group.15
Reflexology is also known as ‘‘zone therapy’’ and in-
volves manual stimulation of reflex points on the feet that
somatotopically correspond to specific areas and organs of
the body. It is based on the theory that all organs are re-
presented by various points on the feet, forming a map of the
whole body, and that massaging specific areas of feet can
affect corresponding target organs.
Clinical experience indicated that reflexology might al-
leviate fatigue and sleep disturbances. The aim of this study
was therefore to evaluate the effect of reflexology on fa-
tigue, pain, and QOL in women with breast cancer during
adjuvant radiation therapy.
Methods
Subjects
The study included 72 breast cancer patients scheduled for
adjuvant radiation therapy for 6 consecutive weeks, 5 days a
week. Participants were recruited to the experimental or
control groups according to their preference. All patients
signed informed consent. Exclusion criteria included the
following: coagulation disorders and concurrent CAM treat-
ments outside the framework of this study.
Reflexology treatments were administered once a week
by a qualified therapist, began concurrently with radiation
therapy, and continued for 10 weeks (for up to 4 weeks after
the completion of radiation treatments).
Reflexology treatments were provided by a senior re-
flexologist, who graduated a 3-year course in one of the
colleges accredited by the Israeli Reflexology Association,
with 13 years of clinical experience. Treatment sessions
followed a structured protocol and included a standardized
protocol (20 min) of manipulation of the areas, which rep-
resent body organs on plantar areas of the feet using sys-
tematic massage horizontally and vertically (a crawling
method), and massaging of spleen, stomach, and heart ar-
eas in a circular clockwise motion. This protocol was
followed by an additional 10 min of individualized ap-
proach adapted to each patient, according to her current
symptoms and involved manipulations of plantar and
dorsal areas of the feet.
The control group received no additional treatment.
Fatigue, pain, QOL, and quality of sleep in both groups
were assessed by self-reported questionnaires at week 1 (as
baseline), week 5, and week 10.
All treatments were delivered at the Cancer Center of the
Sheba Medical Center. The study was approved by the local
Human Subject Review Board and registered at the Clin-
icalTrials.gov NCT00825682.
Tools
Pain, fatigue, and depression are subjective phenomena
that are usually assessed by self-reported questionnaires and,
therefore, lack an objective evaluation. To minimize the
inherent bias, a pain-insomnia-fatigue cluster that has been
characterized by Pud et al. was evaluated, who also dem-
onstrated that differences in functional status and QOL
based on different symptom experiences were not only
statistically significant but also clinically significant.6 This
cluster analysis is based on the Multidimensional Quality of
Life Scale-Cancer questionnaire (MQOLS-CA), the Lee
Fatigue Scale (LFS), the General Sleep Disturbance Scale
(GSDS), and a numeric rating scale of pain intensity. The
Hebrew versions of these questionnaires were used, all trans-
lated and validated by Pud et al.6 as follows:
The LFS16 assesses the degree of fatigue and energy and
includes 18 items that describe feelings and behaviors as-
sociated with fatigue on a 0–10 Likert scale. The Cron-
bach’s a internal reliability coefficient of the English
version is 0.9617 and of the Hebrew translation is 0.93.6 In
the present study the reliability obtained at the three time
points ranged between 0.90 and 0.94.
The GSDS18 examines several aspects of sleep disorders
and includes 21 items that describe feelings and behaviors
associated with sleep and dealing with insomnia during the
previous week. It uses a 0 (never) to 7 (every day) Likert
scale on questions such as feeling nervous during the day;
falling asleep while unplanned; and using sleeping pills. The
Cronbach’s a reliability coefficient of its English version is
0.77,17 and its validity and reliability have been established
in cancer patients.19 The reported Cronbach’s a internal
reliability of the Hebrew version is 0.8.6 In this study, the
reliability coefficients obtained at the three time points were
0.71, 0.79, and 0.84, respectively.
The MQOLS-CA20 includes 44 items describing different
forms in which the disease may affect patient’s QOL. For
each item, subjects are asked to mark the number that best
describes their feelings right now, in a Likert scale ranging
REFLEXOLOGY FOR SYMPTOM RELIEF DURING RADIOTHERAPY
between 0 and 10. Items include feelings of happiness,
anxiety levels, how the disease affects social ties, etc. The
reliability coefficient of the English version of the ques-
tionnaire in different studies ranges between 0.67 and 0.96.
The English validation of the questionnaire was based on the
correlations with other QOL measures and obtained signif-
icant correlations ranging between 0.37 and 0.65. The
Cronbach’s a reliability coefficient of the Hebrew version of
the questionnaire is 0.89.6 The reliability coefficients in this
study ranged between 0.90 and 0.93.
The pain assessment was based on the Visual Analogue
Pain Scale (a 0–10 scale). Subjects were asked to rate the
current pain level, the average pain level during the last
week, and the maximal pain level during the last week.
Statistical analysis
To test the hypotheses that the experimental group will
show a greater reduction in the fatigue index, a greater
improvement in the sleep quality index, a greater im-
provement in the QOL, and reduction in pain compared to
the control group, repeated measurements of analyses of
variances were conducted with time of measurement as
the repeated measurements (three time points) and group
as the between-subjects effect. Significant effects were
followed by Fisher least significant difference post hoc
comparisons.
Results
Seventy-two women were recruited to the study as fol-
lows: 47 chose to participate in the experimental arm and 25
women chose to participate in the control arm. The majority
of the patients who declined participation in the study (re-
flexology) group did it as they were reluctant to arrive at the
hospital on a weekly basis in addition to the already sched-
uled treatments and checkups.
Ten women, five from each group, did not begin the
study. In addition, eight women from the experimental
group did not complete all reflexology treatments (Fig. 1).
Reasons for dropping out included: not attending the sec-
ond and/or third treatment due to personal reasons (lack
of time, distance from the clinic, etc.). To reduce the bias,
a semi-intent-to-treat analysis was performed adding
the four cases that dropped after the first measurement/
FIG. 1. Flow of participants through the trial.
3
treatment. For missing observations, ‘‘last value carried
forward’’ method was used. Accordingly, the final analysis
included 38 women in the experimental group and 20 in the
control group.
Demographic data
The participant’s age ranged between 31 and 77 years
(average = 53.7, SD = 10.8). There was no statistical differ-
ence between the two groups [t(56) = 0.71, p = 0.48]. Most of
the women (77.6%) were married, 10.3% lived alone, and
59% had a diagnosis of additional chronic disease (asthma,
diabetes, hypertension, hyperthyroidism, and epilepsy). There
was no statistical difference in the prevalence of background
diseases between the groups (w2(1) = 1.63; p = 0.20).
The patients in this study were all diagnosed with invasive
breast cancer (no ductal carcinoma in situ, stage 0 disease).
Locally advanced breast cancer (stage 3) was diagnosed among
14 (29.8%) and 9 (36%) of the women; stage 2—among 19
(40.4%) and 10 (40%); and stage 1—among 14 (29.8%) and 6
(24%) of the women in the treatment and control arms, re-
spectively. There was no statistical difference in cancer stage
between the two groups (w2 = 0.39, p = 0.82).
Upon the recruitment to the study no significant differ-
ences were observed between the two groups in terms of
fatigue levels, quality of sleep, QOL, current pain, average
pain, and maximum pain levels during the last week:
p-values of the differences between the groups as assessed
by t tests for independent samples were 0.62, 0.49, 0.61,
0.25, 0.33, and 0.57, respectively (Table 1).
The analysis of the fatigue scale demonstrated a signifi-
cant effect of time of measurement [F(2, 110) = 6.77,
p = 0.002], and most importantly, a significant interaction
[F(2, 110) = 4.50, p = 0.01]. Fatigue levels increased in the
control group between the first and second measurement
( p < 0.001) and between the second and third measurement
( p < 0.05), while no increase in fatigue was observed in the
experimental group (Fig. 2).
Figure 3 presents quality of sleep levels measured in both
groups at the three time points. A significant interaction
between group and time was obtained for the sleep quality
measure [F(2, 112) = 3.44, p = 0.04]. The source of the in-
teraction stems from an improved sleep quality in the ex-
perimental group, as demonstrated by comparison between
the first and the third measures ( p = 0.02). No significant
effects of time or group were obtained.
Table 1. Means and Standard Deviations of the
Dependent Variables, in the Premeasure, Separately
for the Experimental and Control Groups
Experimental group Control group
Measure Mean S.D. Mean S.D.
Fatigue levels 3.92 1.86 3.68 1.56
Quality of sleep 2.53 0.96 2.35 0.84
Quality of life 4.27 1.35 4.09 1.13
Current pain 1.63 2.49 0.90 1.74
Average pain 1.95 2.49 1.30 2.20
Maximum pain 2.32 3.34 1.80 3.05
4 TARRASCH ET AL.
FIG. 2. Interaction between time of measurement and
group on fatigue levels (Lee Fatigue Scale). Fatigue levels
(Lee Fatigue Scale) of both groups measured at three time
points: (1) at the beginning of the study, (2) after 5 weeks
reflexology alongside radiation treatment, and (3) after 10
weeks of reflexology treatment.
The QOL (Fig. 4) was also assessed in both groups at the
three time points and demonstrated a significant interaction
between group and time [F(2, 112) = 4.06, p = 0.02]. The
source of the interaction stems from a significant reduction
in the QOL in the control group in the second ( p = 0.01) and
third ( p = 0.03) measures. No significant effects of time or
group were obtained.
Pain levels throughout the study are presented in Figure 5.
There was no significant difference between the groups in
the percentage of women who reported suffering from pain
at presentation (w2(1) = 1.63; p = 0.20). The analyses of cur-
rent pain, average pain during the last week, and maximum
pain level during the last week yielded significant or mar-
ginally significant interactions between group and time [F(2,
112) = 1.95, p = 0.15; F(2, 112) = 2.31, p = 0.10; and F(2,
112) = 3.81, p = 0.03], respectively.
FIG. 3. Interaction between time of measurement and
group on quality of sleep (General Sleep Disturbance Scale).
Quality of sleep levels (General Sleep Disturbance Scale)
measured in both groups at three time points: (1) at the
beginning of the study, (2) after 5 weeks reflexology
alongside radiation treatment, and (3) after 10 weeks of
reflexology treatment.
FIG. 4. Interaction between time of measurement and
group on quality of life (Multidimensional Quality of
Life Scale-CA index). Quality of life (the Multidimen-
sional Quality of Life Scale-Cancer questionnaire index)
measured in the groups at three time points: (1) at the
beginning of the study, (2) after 5 weeks reflexology
alongside radiation treatment, and (3) after 10 weeks of
reflexology treatment.
As can be seen in Figure 5a–c, while no significant dif-
ferences were observed in the pain measures in the experi-
mental group, there was a significant increase in the current
pain level in the control group between the first and the
second ( p = 0.01) and the third ( p = 0.03) measurements.
The average pain level also rose significantly in the control
group between the first and the second measurements
( p = 0.03) and declined between the second and the third
measurements ( p = 0.02). A significant increase between the
first and the second ( p = 0.003) and the third ( p = 0.05)
measurements of the worst pain level was also observed in
the control group.
Discussion
The effect of reflexology on the pain-insomnia-fatigue
symptom cluster in women with breast cancer was evalu-
ated, who received adjuvant radiation therapy. Postirradia-
tion fatigue may persist for a considerable period of time.
Reflexology treatment was continued therefore for 4 weeks
after the cessation of radiation treatment, to estimate the
effect of reflexology both as a concurrent treatment to ra-
diotherapy (assessed at 5 weeks since the beginning of the
study) and as a maintenance treatment after the cessation of
radiotherapy (assessed at week 10).
By the end of radiation treatment, significant differences
in fatigue, sleep, pain, and QOL were detected between the
reflexology and control groups: the control group experi-
enced significantly higher levels of fatigue during radio-
therapy, while no increase in fatigue was observed in the
reflexology group, which even showed a significant im-
provement in the quality of sleep. Furthermore, while the
QOL in the control group deteriorated after 5 and 10 weeks
of radiation therapy, it was virtually unaffected in the re-
flexology group.
While the mechanism of reflexology is still not clear, it
shares a common philosophical background with acu-
puncture and includes some elements of relaxation and
REFLEXOLOGY FOR SYMPTOM RELIEF DURING RADIOTHERAPY
FIG. 5. Interaction between time of measurement and
group on pain level measurements. Current (a), average (b),
and strongest (c) pain levels measured in the groups at three
time points: (1) at the beginning of the study, (2) after 5
weeks reflexology alongside radiation treatment, and (3)
after 10 weeks of reflexology treatment.
massage treatments. Sharp et al. evaluated the effect of
reflexology and massage versus self-initiated support (SIS)
on QOL following surgery for breast cancer. Both reflex-
ology and massage had statistically significant effects on
QOL compared to SIS, which were clinically worthwhile
for reflexology.21
Findings of this study are in line with conclusions of the
review of mind–body treatments for the pain-fatigue-sleep
disturbance cluster in cancer patients.22 This review dem-
5
onstrated that fatigue and sleep disturbances were the most
common symptoms improved by mind–body interventions,
while relaxation, which is often experienced during re-
flexology treatment, was reported to improve pain and
sleep disturbance. None of the studies however demon-
strated concurrent improvement in all three symptoms.
A recently published meta-analysis on massage therapy
in cancer pain found beneficial effect of massage for relief
of cancer pain, while reflexology appeared to be more
effective than body or aroma massage.23 A significant
difference between the levels of the worst pain between
the two groups at the second measurement ( p = 0.003) was
also demonstrated. Although a similar trend was noted
for the current pain and the average pain, the differences
between the groups did not reach statistical significance. It
is possible that a failure to detect a significant differ-
ence between the groups stems from a relatively small
sample size.
The most impressive result of this study was ameliora-
tion of CRF. This finding is in concordance with results of
other studies of CAM modalities. A large study found
significant improvement in postchemotherapy CRF and in
QOL after 6 weeks of acupuncture treatment.24 Iyengar
Yoga was reported to improve fatigue in breast cancer
survivors,25 and yoga treatment for breast cancer patients
provided during radiotherapy period also demonstrated a
reduction in fatigue compared with stretching exercise
group, but no between-group differences for sleep quality
were detected.26 Massage therapy in patients with ad-
vanced cancer was found to be superior to simple-touch
sessions for immediate pain and mood. However, no sig-
nificant differences were found between the groups in
sustained pain, worst pain, or QOL.27
The inflammatory origin of CRF, probably through acti-
vation of pro-inflammatory cytokine network, has been
suggested by the review on mechanisms, risk factors, and
treatments for CRF.28 It was also demonstrated that in-
creased levels of C-reactive protein and IL-1 receptor an-
tagonist were associated with increase in fatigue both in
early breast cancer and in prostate cancer patients undergo-
ing radiotherapy.29 Furthermore, a significant influence of
skin erythema on pro-inflammatory cytokines and fatigue in
breast cancer patients receiving adjuvant radiation therapy
was demonstrated.30
It is of interest to note that some of the CAM interven-
tions that had beneficial effect on CRF such as acupuncture,
yoga, and massage have also been reported to exert an anti-
inflammatory activity.31–34 The previous study that dem-
onstrated amelioration of multiple sclerosis symptoms by
reflexology35 may also indicate that reflexology treatment
might have an anti-inflammatory effect.
To the best of our knowledge, this is the first report on the
effect of reflexology on pain-insomnia-fatigue cluster in
breast cancer patients during adjuvant radiation therapy. The
study had several limitations as follows: the patients were
allocated to the experimental and control groups according
to their preference and not through a randomization proce-
dure. The two groups however were similar at the baseline
in terms of demographics, background diseases, the levels of
fatigue and sleep disturbances, QOL, or pain. In addition,
due to the lack of an active control group, it may be that the
choice of participation in the reflexology group has resulted
6 TARRASCH ET AL.
in some expectations leading to an inherent bias. The sample
size was relatively small, but despite the small statistical power,
significant improvements in the reflexology group were able to
be demonstrated, compared with the control group.
Conclusions
The results of the present study indicate that reflexology
may have a positive effect on fatigue, quality of sleep, pain,
and QOL in breast cancer patients.
In view of the fact that inadequate treatment of fatigue
may considerably compromise both the QOL of cancer pa-
tients and the adherence to treatment protocol, there is a need
for the development of interventions for this debilitating
symptom. Further randomized controlled studies of non-
pharmacologic approaches such as acupuncture, yoga, mas-
sage, and reflexology should therefore be encouraged.
Acknowledgment
The authors are grateful to Mrs. Lihi Geva for providing
reflexology treatments to the patients.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Dorit Gamus, MD, PhD
Complementary and Integrative Medicine Service
Sheba Medical Center
Ramat-Gan 52621
Israel
E-mail: dorit.gamus@sheba.health.gov.il