Preventive Care in Nursing and Midwifery Journal
Volume 16, Issue 2 (4-2026)
Prev Care Nurs Midwifery J 2026, 16(2): 3-12 |
Back to browse issues page
Ethics code: IR.IUMS.REC.1403.1154
Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Hosseini S E, Amirpour M, Javadi M. The Effect of Foot Reflexology Massage on Pain and Fatigue after Lumbar Spine Surgery: A Randomized Controlled Trial. Prev Care Nurs Midwifery J 2026; 16 (2) :3-12
URL: http://nmcjournal.zums.ac.ir/article-1-1027-en.html
URL: http://nmcjournal.zums.ac.ir/article-1-1027-en.html
Nursing and Midwifery Care Research Center, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran , esmat.hosseini.110@yahoo.com
Full-Text [PDF 920 kb]
(128 Downloads)
| Abstract (HTML) (359 Views)
Table 2: Comparison of pain in the two intervention and control groups at different times of the study
Note. Values are presented as mean (standard deviation); ns = not significant; GG: Greenhouse-Geisser.
Table 3: Comparison of fatigue in the two intervention and control groups at different times of the study
Note. Values are presented as mean (standard deviation); ns = not significant; GG: Greenhouse-Geisser
Full-Text: (58 Views)
Introduction
Low back pain is the second most prevalent cause of chronic pain after headache, with up to 50–80% of adults experiencing it in their lifetime, sometimes resulting in surgery [1]. Spinal surgery is a major surgical procedure and is one of the most common types that leads to severe, long-term postoperative pain. [2] While most spinal surgeries are performed to relieve pain, the procedure itself is very painful and is undesirable for many, which leads to patient dissatisfaction with the results of the surgery, and postoperative pain is often not adequately treated [3].
Pain and fatigue following surgery are common experiences for millions of people worldwide. Since the goal of medicine is to establish and maintain health reducing suffering, effective pain relief and fatigue reduction after surgery are crucial [4].
Although drug therapy is the most effective tool for nurses to reduce pain and fatigue in patients, the side effects of drugs, necessitate the use of non-pharmacological methods to reduce pain and fatigue in addition to medication [5]. Non-pharmacological methods are becoming more and more popular, and it is estimated that one in three people will use these treatments during their lifetime for common diseases such as back problems, headaches, anxiety, and depression [6]. Most of these interventions are inexpensive and easy to perform, and are often without known side effects or risks, and are used alone or in combination with other methods. One non-pharmacological method is foot massage therapy, which is performed through reflexology [7]. Today, massage therapy is one of the most widespread forms of complementary therapies in the United States [8]. These methods are one of several care methods in which nurses reduce pain and make patients feel good. Complementary methods such as massage and muscle relaxation provide comfort and a sense of calm, correct physical dysfunction, change physiological responses, and improve vital signs[9] . Foot reflexology massage has a comprehensive function, meaning that in addition to reducing physical problems (pain, fatigue, physiological indicators, etc.), it also affects the psychological dimension (sleep, anxiety, depression, stress, etc.) of humans, and as a result, it leads to a reduction in the physical, psychological, and social dimensions of pain and fatigue [10].
The Gate Control Theory provides the physiological basis for massage's efficacy. By applying controlled tactile stimulation, massage generates sensory signals that compete with and inhibit pain transmissions to the brain. This process shifts the focus from nociceptive stimuli to positive physical contact, while simultaneously triggering the release of neurotransmitters like endorphins and serotonin to modulate the patient’s response to surgical stress [11].
Various studies have shown the positive effects of reflexology in various conditions. In a systematic review of 44 studies on the effects of reflexology on sleep, fatigue, and pain, Lee describes reflexology as a nursing intervention and a method for improving sleep and fatigue, and considers its effects on pain and other variables to require further study [12].The effectiveness of foot reflexology massage has been shown to reduce pain after cesarean section and appendectomy [13, 14] , and reduce pain intensity and fatigue after coronary artery bypass graft surgery [15]. However, specific data regarding the application of reflexology in the neurosurgery recovery phase remains limited.
By incorporating reflexology into postoperative care, nurses can proactively address discomfort, thus preventing complications such as immobility, deep vein thrombosis, and muscle atrophy, which are linked with prolonged bed rest and unmanaged pain [16].
Furthermore, reflexology promotes relaxation, reduces anxiety, and enhances overall well-being, which are vital components of holistic preventive care [17]. Such interventions can be integrated into nursing protocols to support early mobilization and functional recovery, thereby reducing hospitalization duration and healthcare costs. Importantly, reflexology is non-invasive, cost-effective, and easy to administer, making it accessible as a preventive strategy within various healthcare settings [18].
Considering the importance of reducing complications after spinal surgery and knowing that pharmacological methods of pain relief, in addition to being costly, have numerous complications, the use of non-pharmacological methods of pain control is recommended.
Objectives
Considering that patients complain of surgical pain and fatigue due to discomfort after spinal surgery, this study was designed to investigate the effect of foot reflexology massage on pain and fatigue after lumbar spine surgery.
Methods
Study Design
This study was a randomized controlled trial with a parallel-group pretest–posttest design conducted in Yasuj Province, Iran between September 2017 and November 2019.
Participants and Sampling
The target population consisted of patients referred to Shahid Beheshti Hospital, affiliated with Yasuj University of Medical Sciences, Yasuj, Iran, for lumbar spine surgery necessitated by intervertebral disc herniation or spinal canal stenosis. Participants were recruited based on a set of eligibility criteria, including a history of chronic low back pain for at least three months prior to surgery, full consciousness throughout the study period, an age range of 35 to 60 years, a diagnosis of moderate lumbar spinal stenosis confirmed via MRI by a physician, and a Body Mass Index (BMI) between 16.5 and 30 $kg/m^2$. Conversely, individuals with massage intolerance, lower extremity numbness or paralysis, peripheral vascular diseases, substance abuse, those using patient-controlled analgesia (PCA) pumps, or cases involving intervertebral disc rupture and severe spinal stenosis were excluded.
To maintain cultural sensitivity and patient comfort, foot reflexology was performed by gender-matched certified therapists (female for female participants and male for male participants). Both therapists held nursing degrees with equivalent clinical experience and received certification from the same massage therapy center. To minimize confounding variables, all surgical procedures were performed by the same surgeon, and participants received standardized analgesic protocols at equivalent doses.
Participants were recruited through convenience sampling and then randomly assigned to either the experimental or control group using a computer-generated randomization sequence. This sequence was produced using the RANDBETWEEN function in Microsoft Excel to ensure a stochastic and unbiased distribution of subjects across the study arms [19].
The sample size was calculated based on a two-group comparison of means using effect size estimates from a previous randomized clinical trial investigating foot reflexology on fatigue outcomes [20], with a significance level of 0.05 and a power of 90%. This resulted in 31 participants per group. To account for a potential 10% attrition rate, the final sample size was increased to 34 participants per group, resulting in a total of 68 patients.
Intervention
Patients were maintained on complete bed rest (CBR) for 6 to 8 hours postoperatively. Depending on ward routines and patient conditions, the intervention was performed the following morning between 9:00 and 11:00 AM. Each participant in the experimental group received a detailed explanation of the procedure and was reassured that the massage would not interfere with their standard care. To avoid confounding the effects of the intervention with peak narcotic activity, the massage was administered at least 4 hours after analgesic medication, coinciding with the decline in their plasma concentration or half-life [20].
Prior to the intervention, the researcher sanitized their hands with warm water and applied refined extra-virgin olive oil (Samin Brand) to ensure adequate warmth and skin lubrication. Participants were placed in a supine position and instructed to remain quiet unless communication was necessary. During the session, each leg was supported and slightly elevated with a pillow, which was removed upon completion. The reflexology was performed using circular thumb and finger pressure on specific pedal reflex zones.
The procedure began with a 5-minute relaxation phase, including effleurage, warm-up frictions, diaphragm line release, and the solar plexus technique [21]. This was followed by 10 minutes of targeted massage on the pituitary, solar plexus, and spinal reflex points. The total duration of the intervention was 30 minutes (15 minutes per foot). For the control group, the feet were oiled at 15-minute intervals without applying any therapeutic pressure, ensuring an equivalent volume of olive oil was used. In both groups, pain intensity and fatigue were assessed by the same blinded evaluator at baseline (pre-intervention), and subsequently at 30, 60, 90 minutes, and 24 hours’ post-intervention.
Instruments and Measures (Validity & Reliability)
To collect data, a demographic form, and visual analog scale (VAS) were used. The demographic form included age, gender, marital status, level of education, hospitalization history and surgical history.
A visual analog scale (VAS) was used to measure patients' pain and fatigue, which was rated from 0 (absence of pain and fatigue symptoms) to 10 (maximum severity of symptoms) [21].
The patient was asked to select the corresponding point on the line that indicated the severity of his pain and fatigue (separately). For this purpose, the scale was shown to the patient before the intervention and the necessary explanation was given to him. The validity and reliability of this tool have been assessed in previous studies, and Cronbach's alpha coefficients have been reported to be 0.86 (95%CI 0.84–0.88) [22].
To measure the reliability of the questionnaire, it was administered to 20 patients and then Cronbach's alpha coefficient was calculated and finally this number was excluded from the main sample. In this study, the reliability of the questionnaire was confirmed for pain with Cronbach's alpha of 0.89 and fatigue with 0.91.
Statistical Analysis
Statistical analyses were performed using SPSS version 20.0 (IBM Corp., Armonk, NY, USA). The normality of all continuous variables at each measurement point was assessed using the Shapiro–Wilk test, confirming that the assumption of normal distribution was met. Accordingly, parametric tests were applied.
Baseline characteristics were compared between the intervention and control groups using the independent t test for continuous variables and the chi square or Fisher’s exact test for categorical variables. Repeated measures analysis of variance (RM ANOVA) was employed to examine changes in pain and fatigue over time (before the intervention, immediately after, 60 minutes, 90 minutes, and 24 hours) and to assess differences between the two study groups across these time points. Mauchly’s test was used to evaluate the assumption of sphericity; when violated, the Greenhouse–Geisser correction was applied. Pairwise comparisons were conducted using the Bonferroni-adjusted post hoc test.
All analyses were performed using a per protocol approach, as all participants completed the study without dropout.
Effect sizes for RM ANOVA were reported using partial eta squared (η²). A significant level of 0.05 was adopted for all statistical tests.
Result
Of the 95 patients assessed, 68 met the inclusion criteria and were enrolled in the study (Figure 1). Of these, 34 were randomly assigned to the experimental group with a mean (SD) age of 45.67 (11.87) years, and 34 to the control group with a mean age of 45.08 (11.75) years. All participants completed the study, and no attrition occurred. The two groups were comparable at baseline, with no statistically significant differences in demographic characteristics (Table 1).
Overall, pain levels changed significantly over time in both groups. However, the pattern of change differed between the two groups.
There was a significant main effect of time (p < 0.001), indicating that pain scores varied across all measurement points. A significant group effect was also observed (p = 0.005), showing that overall pain was lower in the experimental group compared with the control group.
Low back pain is the second most prevalent cause of chronic pain after headache, with up to 50–80% of adults experiencing it in their lifetime, sometimes resulting in surgery [1]. Spinal surgery is a major surgical procedure and is one of the most common types that leads to severe, long-term postoperative pain. [2] While most spinal surgeries are performed to relieve pain, the procedure itself is very painful and is undesirable for many, which leads to patient dissatisfaction with the results of the surgery, and postoperative pain is often not adequately treated [3].
Pain and fatigue following surgery are common experiences for millions of people worldwide. Since the goal of medicine is to establish and maintain health reducing suffering, effective pain relief and fatigue reduction after surgery are crucial [4].
Although drug therapy is the most effective tool for nurses to reduce pain and fatigue in patients, the side effects of drugs, necessitate the use of non-pharmacological methods to reduce pain and fatigue in addition to medication [5]. Non-pharmacological methods are becoming more and more popular, and it is estimated that one in three people will use these treatments during their lifetime for common diseases such as back problems, headaches, anxiety, and depression [6]. Most of these interventions are inexpensive and easy to perform, and are often without known side effects or risks, and are used alone or in combination with other methods. One non-pharmacological method is foot massage therapy, which is performed through reflexology [7]. Today, massage therapy is one of the most widespread forms of complementary therapies in the United States [8]. These methods are one of several care methods in which nurses reduce pain and make patients feel good. Complementary methods such as massage and muscle relaxation provide comfort and a sense of calm, correct physical dysfunction, change physiological responses, and improve vital signs[9] . Foot reflexology massage has a comprehensive function, meaning that in addition to reducing physical problems (pain, fatigue, physiological indicators, etc.), it also affects the psychological dimension (sleep, anxiety, depression, stress, etc.) of humans, and as a result, it leads to a reduction in the physical, psychological, and social dimensions of pain and fatigue [10].
The Gate Control Theory provides the physiological basis for massage's efficacy. By applying controlled tactile stimulation, massage generates sensory signals that compete with and inhibit pain transmissions to the brain. This process shifts the focus from nociceptive stimuli to positive physical contact, while simultaneously triggering the release of neurotransmitters like endorphins and serotonin to modulate the patient’s response to surgical stress [11].
Various studies have shown the positive effects of reflexology in various conditions. In a systematic review of 44 studies on the effects of reflexology on sleep, fatigue, and pain, Lee describes reflexology as a nursing intervention and a method for improving sleep and fatigue, and considers its effects on pain and other variables to require further study [12].The effectiveness of foot reflexology massage has been shown to reduce pain after cesarean section and appendectomy [13, 14] , and reduce pain intensity and fatigue after coronary artery bypass graft surgery [15]. However, specific data regarding the application of reflexology in the neurosurgery recovery phase remains limited.
By incorporating reflexology into postoperative care, nurses can proactively address discomfort, thus preventing complications such as immobility, deep vein thrombosis, and muscle atrophy, which are linked with prolonged bed rest and unmanaged pain [16].
Furthermore, reflexology promotes relaxation, reduces anxiety, and enhances overall well-being, which are vital components of holistic preventive care [17]. Such interventions can be integrated into nursing protocols to support early mobilization and functional recovery, thereby reducing hospitalization duration and healthcare costs. Importantly, reflexology is non-invasive, cost-effective, and easy to administer, making it accessible as a preventive strategy within various healthcare settings [18].
Considering the importance of reducing complications after spinal surgery and knowing that pharmacological methods of pain relief, in addition to being costly, have numerous complications, the use of non-pharmacological methods of pain control is recommended.
Objectives
Considering that patients complain of surgical pain and fatigue due to discomfort after spinal surgery, this study was designed to investigate the effect of foot reflexology massage on pain and fatigue after lumbar spine surgery.
Methods
Study Design
This study was a randomized controlled trial with a parallel-group pretest–posttest design conducted in Yasuj Province, Iran between September 2017 and November 2019.
Participants and Sampling
The target population consisted of patients referred to Shahid Beheshti Hospital, affiliated with Yasuj University of Medical Sciences, Yasuj, Iran, for lumbar spine surgery necessitated by intervertebral disc herniation or spinal canal stenosis. Participants were recruited based on a set of eligibility criteria, including a history of chronic low back pain for at least three months prior to surgery, full consciousness throughout the study period, an age range of 35 to 60 years, a diagnosis of moderate lumbar spinal stenosis confirmed via MRI by a physician, and a Body Mass Index (BMI) between 16.5 and 30 $kg/m^2$. Conversely, individuals with massage intolerance, lower extremity numbness or paralysis, peripheral vascular diseases, substance abuse, those using patient-controlled analgesia (PCA) pumps, or cases involving intervertebral disc rupture and severe spinal stenosis were excluded.
To maintain cultural sensitivity and patient comfort, foot reflexology was performed by gender-matched certified therapists (female for female participants and male for male participants). Both therapists held nursing degrees with equivalent clinical experience and received certification from the same massage therapy center. To minimize confounding variables, all surgical procedures were performed by the same surgeon, and participants received standardized analgesic protocols at equivalent doses.
Participants were recruited through convenience sampling and then randomly assigned to either the experimental or control group using a computer-generated randomization sequence. This sequence was produced using the RANDBETWEEN function in Microsoft Excel to ensure a stochastic and unbiased distribution of subjects across the study arms [19].
The sample size was calculated based on a two-group comparison of means using effect size estimates from a previous randomized clinical trial investigating foot reflexology on fatigue outcomes [20], with a significance level of 0.05 and a power of 90%. This resulted in 31 participants per group. To account for a potential 10% attrition rate, the final sample size was increased to 34 participants per group, resulting in a total of 68 patients.
Intervention
Patients were maintained on complete bed rest (CBR) for 6 to 8 hours postoperatively. Depending on ward routines and patient conditions, the intervention was performed the following morning between 9:00 and 11:00 AM. Each participant in the experimental group received a detailed explanation of the procedure and was reassured that the massage would not interfere with their standard care. To avoid confounding the effects of the intervention with peak narcotic activity, the massage was administered at least 4 hours after analgesic medication, coinciding with the decline in their plasma concentration or half-life [20].
Prior to the intervention, the researcher sanitized their hands with warm water and applied refined extra-virgin olive oil (Samin Brand) to ensure adequate warmth and skin lubrication. Participants were placed in a supine position and instructed to remain quiet unless communication was necessary. During the session, each leg was supported and slightly elevated with a pillow, which was removed upon completion. The reflexology was performed using circular thumb and finger pressure on specific pedal reflex zones.
The procedure began with a 5-minute relaxation phase, including effleurage, warm-up frictions, diaphragm line release, and the solar plexus technique [21]. This was followed by 10 minutes of targeted massage on the pituitary, solar plexus, and spinal reflex points. The total duration of the intervention was 30 minutes (15 minutes per foot). For the control group, the feet were oiled at 15-minute intervals without applying any therapeutic pressure, ensuring an equivalent volume of olive oil was used. In both groups, pain intensity and fatigue were assessed by the same blinded evaluator at baseline (pre-intervention), and subsequently at 30, 60, 90 minutes, and 24 hours’ post-intervention.
Instruments and Measures (Validity & Reliability)
To collect data, a demographic form, and visual analog scale (VAS) were used. The demographic form included age, gender, marital status, level of education, hospitalization history and surgical history.
A visual analog scale (VAS) was used to measure patients' pain and fatigue, which was rated from 0 (absence of pain and fatigue symptoms) to 10 (maximum severity of symptoms) [21].
The patient was asked to select the corresponding point on the line that indicated the severity of his pain and fatigue (separately). For this purpose, the scale was shown to the patient before the intervention and the necessary explanation was given to him. The validity and reliability of this tool have been assessed in previous studies, and Cronbach's alpha coefficients have been reported to be 0.86 (95%CI 0.84–0.88) [22].
To measure the reliability of the questionnaire, it was administered to 20 patients and then Cronbach's alpha coefficient was calculated and finally this number was excluded from the main sample. In this study, the reliability of the questionnaire was confirmed for pain with Cronbach's alpha of 0.89 and fatigue with 0.91.
Statistical Analysis
Statistical analyses were performed using SPSS version 20.0 (IBM Corp., Armonk, NY, USA). The normality of all continuous variables at each measurement point was assessed using the Shapiro–Wilk test, confirming that the assumption of normal distribution was met. Accordingly, parametric tests were applied.
Baseline characteristics were compared between the intervention and control groups using the independent t test for continuous variables and the chi square or Fisher’s exact test for categorical variables. Repeated measures analysis of variance (RM ANOVA) was employed to examine changes in pain and fatigue over time (before the intervention, immediately after, 60 minutes, 90 minutes, and 24 hours) and to assess differences between the two study groups across these time points. Mauchly’s test was used to evaluate the assumption of sphericity; when violated, the Greenhouse–Geisser correction was applied. Pairwise comparisons were conducted using the Bonferroni-adjusted post hoc test.
All analyses were performed using a per protocol approach, as all participants completed the study without dropout.
Effect sizes for RM ANOVA were reported using partial eta squared (η²). A significant level of 0.05 was adopted for all statistical tests.
Result
Of the 95 patients assessed, 68 met the inclusion criteria and were enrolled in the study (Figure 1). Of these, 34 were randomly assigned to the experimental group with a mean (SD) age of 45.67 (11.87) years, and 34 to the control group with a mean age of 45.08 (11.75) years. All participants completed the study, and no attrition occurred. The two groups were comparable at baseline, with no statistically significant differences in demographic characteristics (Table 1).
Overall, pain levels changed significantly over time in both groups. However, the pattern of change differed between the two groups.
There was a significant main effect of time (p < 0.001), indicating that pain scores varied across all measurement points. A significant group effect was also observed (p = 0.005), showing that overall pain was lower in the experimental group compared with the control group.
Table 1. Demographic Characteristics of Participants in the Experimental and Control Groups
| Variable | Category | Experimental group n (%) | Control group n (%) | p-value |
| Gender | Female | 15 (44.1) | 15 (44.1) | 1.000 |
| Male | 19 (55.9) | 19 (55.9) | ||
| Education level | Primary school and less | 14 (41.2) | 16 (47.1) | 0.950 |
| Middle school | 3 (8.8) | 3 (8.8) | ||
| Diploma | 11 (32.4) | 10 (29.4) | ||
| Academic degree | 6 (17.6) | 5 (14.7) | ||
| Marital status | Single | 4 (11.8) | 3 (8.8) | 0.690 |
| Married | 30 (88.2) | 31 (91.2) | ||
| Hospitalization history | Yes | 24 (70.6) | 23 (67.6) | 0.790 |
| No | 10 (29.4) | 11 (32.4) | ||
| Surgical history | Yes | 25 (73.5) | 20 (58.8) | 0.305 |
| No | 9 (26.5) | 14 (41.2) |
Note. Values are presented as frequency (percentage). Statistical tests: chi-square or Fisher’s exact test.
Importantly, the time × group interaction was statistically significant (p < 0.001), suggesting that the trajectory of pain reduction over time differed between the two groups.
Pairwise comparisons revealed no baseline difference between the groups (p = 0.78). After the intervention, pain was significantly lower in the experimental group at 30, 60, and 90 minutes; however, this difference was no longer statistically significant at 24 hours’ post-intervention (p = 0.21) (Table 2).
A similar pattern was observed for fatigue. Fatigue scores changed significantly over time in both groups (p= 0.003), and a significant group effect indicated lower overall fatigue in the experimental group compared with the control group (p = 0.020).
The time × group interaction was also significant (p = 0.004), indicating that fatigue changes over time were not the same in the two groups.
Post hoc comparisons showed no baseline difference between groups (p = 0.401). After the intervention, fatigue was significantly lower in the experimental group immediately after, as well as at 60 and 90 minutes. However, no significant difference was observed at 24-hour post-intervention (p = 0.162) (Table 3).
Pairwise comparisons revealed no baseline difference between the groups (p = 0.78). After the intervention, pain was significantly lower in the experimental group at 30, 60, and 90 minutes; however, this difference was no longer statistically significant at 24 hours’ post-intervention (p = 0.21) (Table 2).
A similar pattern was observed for fatigue. Fatigue scores changed significantly over time in both groups (p= 0.003), and a significant group effect indicated lower overall fatigue in the experimental group compared with the control group (p = 0.020).
The time × group interaction was also significant (p = 0.004), indicating that fatigue changes over time were not the same in the two groups.
Post hoc comparisons showed no baseline difference between groups (p = 0.401). After the intervention, fatigue was significantly lower in the experimental group immediately after, as well as at 60 and 90 minutes. However, no significant difference was observed at 24-hour post-intervention (p = 0.162) (Table 3).
Table 2: Comparison of pain in the two intervention and control groups at different times of the study
| Time | Study Groups | Repeated Measure Analysis of variance | ||||
| Control | Control | Experimental | multiple comparisons: Bonferroni | Main effect of Group | Main effect of Time (GG)* | Time × Group interaction (GG) |
| Before intervention | 5.82 (1.38) | 5.88 (0.95) | 0.78 (ns) | F (1, 66) = 8.28 p = 0.005 η² = 0.111 |
F (2.855, 188.447) = 26.02 p < 0.001 η² = 0.283 |
F (2.855, 188.447) = 11.93 p < 0.001 η² = 0.153 |
| After intervention | 5.29 (1.56) | 3.94 (1.41) | < 0.001 | |||
| 60 minutes | 5.53 (1.72) | 4.26 (1.48) | 0.002 | |||
| 90 minutes | 5.44 (1.56) | 4.15 (1.42) | < 0.001 | |||
| 24 hours | 4.91 (0.96) | 4.65 (1.10) | 0.21 (ns) | |||
Table 3: Comparison of fatigue in the two intervention and control groups at different times of the study
| Time | Study Groups | Repeated Measure Analysis of variance | ||||
| Control | Experimental |
multiple comparisons: Bonferroni | Main effect of Group | Main effect of Time (GG)* | Time × Group interaction (GG) | |
| Before intervention | 4.53 (1.81) | 4.21 (1.30) | 0.401(ns) | F (1, 66) = 5.66 p = 0.020 Partial η² = 0.079 |
F (2.47, 163.03) = 5.49 p = 0.003 Partial η² = 0.077 |
F (2.47, 163.03) = 5.05 p = 0.004 Partial η² = 0.071 |
| After intervention | 4.35 (1.72) | 3.35 (1.32) | 0.009 | |||
| 60 minutes | 4.62 (1.60) | 3.32 (1.27) | 0.001 | |||
| 90 minutes | 4.41 (1.35) | 3.71 (1.36) | 0.035 | |||
| 24 hours | 4.47 (1.24) | 4.03 (1.51) | 0.162(ns) | |||
Discussion
In this study, the main objective was to investigate the effects of massage on pain reduction and fatigue in patients after spinal surgery. The results indicate that massage acts as an effective method for rapid pain relief after surgery, which is likely related to physiological mechanisms such as increased secretion of endorphins and decreased secretion of stress hormones[23]. Some studies in recent years have also shown that post-surgical massage can reduce the severity of patients' pain and have reported the positive effects of massage in reducing pain[24] . In addition, studies by Wang et al. and Mokhtari Nouri et al. have also confirmed the positive effects of reflexology massage in reducing post-surgical pain and the trend of decreasing pain intensity. These results are consistent with the findings of the present study, emphasizing the positive role of massage in reducing pain [25, 26].
The present study demonstrated a significant time-by-group interaction, indicating that foot reflexology massage produces a time-dependent reduction in pain levels, with the most pronounced effects observed at 30-, 60- and 90-minutes’ post-intervention.
A systematic review of 13 randomized controlled trials with 1189 pregnant women was conducted. The results showed that, compared with the control group, foot reflexology massage reduced anxiety and pain in pregnant women, shortened the three stages of labor, and increased satisfaction with childbirth [25]. The results of this study are consistent with the results of the present study, although the target groups are different. Based on the results obtained, studies can be designed to investigate the effect of Parr's reflexology massager on reducing pain in other patients.
In terms of fatigue, the results showed that massage had a short‑term effect, particularly immediately after the intervention and at 60 and 90 minutes afterward; however, no significant difference was observed between the groups at 24 hours. This finding indicates that the beneficial effects of reflexology on fatigue are transient and limited to the immediate postoperative period. These findings are also consistent with other studies, which have shown that reflexology massage can be effective in reducing fatigue [12, 26]. However, the relatively smaller effect sizes observed for fatigue compared to pain suggest that reflexology may have a stronger immediate impact on pain than on perceived fatigue. In a large review study that examined the effect of massage on fatigue, it was shown that massage can be used as a low-cost, safe and easy method to reduce fatigue in patients, especially dialysis patients and those with chronic heart failure [12].
A systematic review of recent research trends and perspectives on foot reflexology found that foot reflexology is a non-invasive complementary therapy that has been increasingly accepted by modern people in recent years. To understand the research trends and perspectives of foot reflexology over the past 31 years, this study used the Web of Science main collection as a data source and two visualization tools, COOC and VOSviewer, to analyze the literature related to the field of foot reflexology from 1991 to 2021. The study found that foot reflexology has a moderating effect on anxiety, fatigue, and cancer, and is the subject of ongoing and future research [27].
In terms of demographic characteristics, homogeneity was observed between the intervention and control groups in the variables of age, sex, marital status, education level, surgical history, and type of surgery. This homogeneity provides greater confidence in interpreting the results and conclusions of the study, as baseline differences between groups have been reduced and the observed effects can be partially attributed to the massage intervention.
This study suggests that complementary therapies such as foot reflexology massage may help improve short‑term postoperative outcomes by alleviating pain and fatigue in the immediate recovery period. While the findings indicate potential value for supporting early postoperative care, the evidence is limited to short‑term effects. However, the absence of significant effects at 24 hours suggests that these benefits are transient and may not persist beyond the immediate postoperative period. Therefore, these results should be interpreted with appropriate caution, and further research is needed to clarify the broader clinical implications.
Several limitations of the present study warrant consideration. First, the single-center design and relatively small sample size may limit the generalizability of the findings. Second, the inherent nature of the reflexology intervention precluded the blinding of participants and therapists, which may introduce potential biases. Furthermore, owing to cultural considerations within the community, gender-concordant therapists (one male, one female) administered the intervention. Although standardized massage techniques were strictly followed, inadvertent variations in the applied pressure cannot be entirely ruled out. Additionally, the psychological influence of the therapists’ presence on the subjective perception of pain, a phenomenon heavily modulated by emotional and psychological factors, cannot be disregarded. Finally, the study was limited to a short-term evaluation period; the lack of a long-term follow-up restricts conclusions regarding the sustained efficacy of the intervention. Future multi-center studies with larger cohorts and extended follow-ups are warranted. To minimize intervention variability, utilizing a single therapist or a single-gender cohort is also recommended.
Conclusion
This randomized controlled trial provides preliminary evidence that foot reflexology may transiently attenuate nociceptive pain and fatigue during the acute postoperative phase following lumbar spine surgery. However, the absence of significant effects at 24-hour follow-up indicates that these benefits are short- lived. While significant reductions were observed in early post-intervention, these effects were not maintained at the 24-hour follow-up. Given its non-invasive and cost-effective profile, reflexology may be considered a supplemental non-pharmacological modality. Nonetheless, rigorously designed investigations with larger cohorts and extended follow-ups remain necessary to definitively establish its longitudinal clinical utility.
Ethics Consideration
The study was carried out in accordance with the declaration of Helsinki, and was approved by Ethics Committee from Yazd University of Medical Sciences with the Ethics Code: IR.SSU.REC.1395.239 (Webpage of ethical approval code is: https://ethics.research.ac.ir/PortalCommittee.php?code=IR.SSU.MEDICINE.REC) as well as confirmed that all research was performed in accordance with relevant guidelines/regulations.
The trial is registered at www.irct.ir under the identification number IRCT20181111041608N1. All protocols were approved by the Ethics Committee of Yazd University of Medical Sciences and the Clinical Trials Center of the Ministry of Health of Iran.
Before the start of the study, the objectives of the research were explained to the participants, and if the patients were willing to participate in the study, written informed consent was obtained from them.
Acknowledgements
The authors express their gratitude to all participants. The results of this study are extracted from master’s thesis No. 23, which was conducted at Shahid Sadoughi University of medical sciences, Yazd.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Funding
This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors' Contributions
Data collection, Amirpour M; Study design and writing the original draft, Jvadi M; Writing the original draft, review, data analysis and editing, Hosseini SE; Conceptualization, writing the original draft, review, and editing, Jvadi M, Hosseini SE.
Artificial Intelligence Utilization
The article was not written using artificial intelligence.
Data Availability Statement
The data analyzed during this study are available from the corresponding author on reasonable request.
In this study, the main objective was to investigate the effects of massage on pain reduction and fatigue in patients after spinal surgery. The results indicate that massage acts as an effective method for rapid pain relief after surgery, which is likely related to physiological mechanisms such as increased secretion of endorphins and decreased secretion of stress hormones[23]. Some studies in recent years have also shown that post-surgical massage can reduce the severity of patients' pain and have reported the positive effects of massage in reducing pain[24] . In addition, studies by Wang et al. and Mokhtari Nouri et al. have also confirmed the positive effects of reflexology massage in reducing post-surgical pain and the trend of decreasing pain intensity. These results are consistent with the findings of the present study, emphasizing the positive role of massage in reducing pain [25, 26].
The present study demonstrated a significant time-by-group interaction, indicating that foot reflexology massage produces a time-dependent reduction in pain levels, with the most pronounced effects observed at 30-, 60- and 90-minutes’ post-intervention.
A systematic review of 13 randomized controlled trials with 1189 pregnant women was conducted. The results showed that, compared with the control group, foot reflexology massage reduced anxiety and pain in pregnant women, shortened the three stages of labor, and increased satisfaction with childbirth [25]. The results of this study are consistent with the results of the present study, although the target groups are different. Based on the results obtained, studies can be designed to investigate the effect of Parr's reflexology massager on reducing pain in other patients.
In terms of fatigue, the results showed that massage had a short‑term effect, particularly immediately after the intervention and at 60 and 90 minutes afterward; however, no significant difference was observed between the groups at 24 hours. This finding indicates that the beneficial effects of reflexology on fatigue are transient and limited to the immediate postoperative period. These findings are also consistent with other studies, which have shown that reflexology massage can be effective in reducing fatigue [12, 26]. However, the relatively smaller effect sizes observed for fatigue compared to pain suggest that reflexology may have a stronger immediate impact on pain than on perceived fatigue. In a large review study that examined the effect of massage on fatigue, it was shown that massage can be used as a low-cost, safe and easy method to reduce fatigue in patients, especially dialysis patients and those with chronic heart failure [12].
A systematic review of recent research trends and perspectives on foot reflexology found that foot reflexology is a non-invasive complementary therapy that has been increasingly accepted by modern people in recent years. To understand the research trends and perspectives of foot reflexology over the past 31 years, this study used the Web of Science main collection as a data source and two visualization tools, COOC and VOSviewer, to analyze the literature related to the field of foot reflexology from 1991 to 2021. The study found that foot reflexology has a moderating effect on anxiety, fatigue, and cancer, and is the subject of ongoing and future research [27].
In terms of demographic characteristics, homogeneity was observed between the intervention and control groups in the variables of age, sex, marital status, education level, surgical history, and type of surgery. This homogeneity provides greater confidence in interpreting the results and conclusions of the study, as baseline differences between groups have been reduced and the observed effects can be partially attributed to the massage intervention.
This study suggests that complementary therapies such as foot reflexology massage may help improve short‑term postoperative outcomes by alleviating pain and fatigue in the immediate recovery period. While the findings indicate potential value for supporting early postoperative care, the evidence is limited to short‑term effects. However, the absence of significant effects at 24 hours suggests that these benefits are transient and may not persist beyond the immediate postoperative period. Therefore, these results should be interpreted with appropriate caution, and further research is needed to clarify the broader clinical implications.
Several limitations of the present study warrant consideration. First, the single-center design and relatively small sample size may limit the generalizability of the findings. Second, the inherent nature of the reflexology intervention precluded the blinding of participants and therapists, which may introduce potential biases. Furthermore, owing to cultural considerations within the community, gender-concordant therapists (one male, one female) administered the intervention. Although standardized massage techniques were strictly followed, inadvertent variations in the applied pressure cannot be entirely ruled out. Additionally, the psychological influence of the therapists’ presence on the subjective perception of pain, a phenomenon heavily modulated by emotional and psychological factors, cannot be disregarded. Finally, the study was limited to a short-term evaluation period; the lack of a long-term follow-up restricts conclusions regarding the sustained efficacy of the intervention. Future multi-center studies with larger cohorts and extended follow-ups are warranted. To minimize intervention variability, utilizing a single therapist or a single-gender cohort is also recommended.
Conclusion
This randomized controlled trial provides preliminary evidence that foot reflexology may transiently attenuate nociceptive pain and fatigue during the acute postoperative phase following lumbar spine surgery. However, the absence of significant effects at 24-hour follow-up indicates that these benefits are short- lived. While significant reductions were observed in early post-intervention, these effects were not maintained at the 24-hour follow-up. Given its non-invasive and cost-effective profile, reflexology may be considered a supplemental non-pharmacological modality. Nonetheless, rigorously designed investigations with larger cohorts and extended follow-ups remain necessary to definitively establish its longitudinal clinical utility.
Ethics Consideration
The study was carried out in accordance with the declaration of Helsinki, and was approved by Ethics Committee from Yazd University of Medical Sciences with the Ethics Code: IR.SSU.REC.1395.239 (Webpage of ethical approval code is: https://ethics.research.ac.ir/PortalCommittee.php?code=IR.SSU.MEDICINE.REC) as well as confirmed that all research was performed in accordance with relevant guidelines/regulations.
The trial is registered at www.irct.ir under the identification number IRCT20181111041608N1. All protocols were approved by the Ethics Committee of Yazd University of Medical Sciences and the Clinical Trials Center of the Ministry of Health of Iran.
Before the start of the study, the objectives of the research were explained to the participants, and if the patients were willing to participate in the study, written informed consent was obtained from them.
Acknowledgements
The authors express their gratitude to all participants. The results of this study are extracted from master’s thesis No. 23, which was conducted at Shahid Sadoughi University of medical sciences, Yazd.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Funding
This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors' Contributions
Data collection, Amirpour M; Study design and writing the original draft, Jvadi M; Writing the original draft, review, data analysis and editing, Hosseini SE; Conceptualization, writing the original draft, review, and editing, Jvadi M, Hosseini SE.
Artificial Intelligence Utilization
The article was not written using artificial intelligence.
Data Availability Statement
The data analyzed during this study are available from the corresponding author on reasonable request.
Type of Study: Orginal research |
Subject:
Nursing
References
1. Mosabbir A. Mechanisms behind the development of chronic low back pain and its neurodegenerative features. Life (Basel). 2022;13(1):1-15. [https://doi.org/10.3390/life13010084] [PMID]
2. Alshammari HS, Alshammari AS, Alshammari SA, Ahamed SS. Prevalence of ihronic pain after spinal surgery: a systematic review and meta-analysis. Cureus. 2023;15(7):1-11. [https://doi.org/10.7759/cureus.41841]
3. Särkilahti I, Reponen E, Skants N. Patient-reported pain, satisfaction, adverse effects, and deviations from ambulatory surgery pain medication. Scandinavian Journal of Pain. 2024;24(1):1-10. [https://doi.org/10.1515/sjpain-2023-0133] [PMID]
4. Reme SE, Munk A, Holter MTS, Falk RS, Jacobsen HB. Pre- and post-operative psychological interventions to prevent pain and fatigue after breast cancer surgery (PREVENT): Protocol for a randomized controlled trial. PLoS One. 2022;17(7):1-25. [https://doi.org/10.1371/journal.pone.0268606] [PMID]
5. Chinnusamy S, Subbarayalu AV, Mani P, Purushothaman VK, Vasanthi RK, Muralidharan CK, et al. Combined efficacy of foot reflexology and back massage on pain and fatigue in patients undergoing hemodialysis. International Journal of Therapeutic Massage and Bodywork. 2025;18(2):19-27. [https://doi.org/10.3822/ijtmb.v18i2.1097] [PMID]
6. Keskin AY, Molu B. Nurses' attitudes toward holistic and complementary medicine in pain management. Pain Manag Nursing. 2025;26(3):298-305. [https://doi.org/10.1016/j.pmn.2024.11.008] [PMID]
7. Ouda MM, Al Ghadeer H, Hussein MF, Elfeshawy R, Mahmoud NF, Elsayed AIIJTMJoN. Effect of foot reflexology on pain and fatigue levels regarding insulin injection among diabetic children. The Malaysian Journal of Nursing. 2025;16(4):274-285. [https://doi.org/10.31674/mjn.2025.v16i04.027]
8. Levin J, Bradshaw M. Prevalence and determinants of massage therapy use in the U.S.: Findings from the 2022 National Health Interview Survey. Explore (NY). 2024;20(6):103-115. [https://doi.org/10.1016/j.explore.2024.05.013] [PMID]
9. Zhuang Q, Yin Y, Liu Z, Zhang L, Li H. Effect of music therapy on relieving the pain and distress of children undergoing venipuncture: a systematic review and meta-analysis. Complementary Therapies in Clinical Practice. 2025;60(10):1-18. [https://doi.org/10.1016/j.ctcp.2025.101994] [PMID]
10. Hull R. The Complete guide to reflexology. 3th ed: Simon and Schuster; 2023. [https://www.simonandschuster.co.uk/books/The-Complete-Guide-to-Reflexology/Ruth-Hull/9781644116258]
11. Sluka KA. Mechanisms and management of pain for the physical therapist-E-BOOK. 3th ed: Elsevier Health Sciences; 2025. [https://pubhtml5.com/ylgr/cudv/Mechanisms_and_Management_of_Pain_for_the_Physical_Therapist_Second_E]
12. Lee J, Han M, Chung Y, Kim J, Choi J. Effects of foot reflexology on fatigue, sleep and pain: a systematic review and meta-analysis. Journal of Korean Academy of Nursing. 2011;41(6):821-833. [https://doi.org/10.4040/jkan.2011.41.6.821] [PMID]
13. Zhang Y, Qin X, Li Q, Ma J, Rao L, Zhou J. Hand and foot massage on pain management after cesarean section: a meta-analysis. Pain Management Nursing. 2025;26(2):237-244. [https://doi.org/10.1016/j.pmn.2024.10.017] [PMID]
14. Mohamed Elghareeb Allam S, Ahmed Mohammed Elmetwaly A, Mokhtar Mokhtar I. Impact of the finger handheld relaxation technique on pain intensity and stress among post appendectomy patients. Egyptian Journal of Health Care. 2023;14(3):103-115. [https://doi.org/10.21608/ejhc.2023.313529]
15. Özkan E, Bayrak NG. Efficacy of massage therapy in alleviating pain and anxiety post-cardiac surgery: A systematic review and meta-analysis. Perioperative Care and Operating Room Management. 2025;38:1-13. [https://doi.org/10.1016/j.pcorm.2025.100465]
16. Almutairi BNA, Almutary SA. Nursing interventions for managing chronic pain in older adults: a comprehensive review. The Review of Diabetic Studies. 2024;20(s5):261-275. [https://doi.org/10.70082/zeqzps79]
17. Ajari EE. Mindfulness meditation as a complementary health therapy: a useful import into aarica? European Journal of Environment and Public Health. 2020;4(2):1-10. [https://doi.org/10.29333/ejeph/8328]
18. Poyyamozhi M, Ravichandran PT, Bharathidass K, Murugesan B, Vadivelan K, Alsafyani M, et al. Investigating the use of luminous capsule bubble tiles in smart structures to improve reflexology. Buildings. 2025;15(7):1-15. [https://doi.org/10.3390/buildings15071092]
19. Shibasaki WM, Martins RP. Simple randomization may lead to unequal group sizes. Is that a problem? American Journal of Orthodontics and Dentofacial Orthopedics. 2018;154(4):600-605. [https://doi.org/10.1016/j.ajodo.2018.07.005] [PMID]
20. Sayari S, Ghorbani R, Nobahar M. Effect of foot reflexology on sleep quality and severity of fatigue in patients with acute myocardial infarction: A double-blind randomized clinical trial. Koomesh. 2021;23(23):327-337. [https://brieflands.com/journals/koomesh/articles/149951]
21. Begum MR, Hossain MA. validity and reliability of visual analogue scale (VAS) for pain measurement. Journal of Medical Case Reports and Reviews. 2019;2(11):1153-1157. [https://doi.org/10.1111/j.1553-2712.2001.tb01132.x] [PMID]
22. Goudman L, Pilitsis J, Billet B, De Vos R, Hanssens K, Billot M, et al. The level of agreement between the numerical rating scale and visual analogue scale for assessing pain intensity in adults with chronic pain. Anaesthesia. 2024;79(2):128-138. [https://doi.org/10.1111/anae.16151] [PMID]
23. Liu C, Chen X, Wu S. The effect of massage therapy on pain after surgery: A comprehensive meta-analysis. Complementary Therapies in Medicine. 2022;71(102892.):1-18. [https://doi.org/10.1016/j.ctim.2022.102892] [PMID]
24. Cole JS, Olson AD, Dupont-Versteegden EE. The Effects of massage therapy in decreasing pain and anxiety in post-surgicalpatients with breast cancer: a systematic review and meta-analysis. Global Aadvances in Integrative Medicine and Health. 2024;13(II):1-13. [https://doi.org/10.1177/27536130241245099] [PMID]
25. Yang JM, Li ZQ, Ye H, Wu YL, Long Y, Zhong YB, et al. Effects of foot reflexology massage on pregnant women: a systematic review and meta-analysis of randomized controlled studies. Scientific Reports. 2024;14(1):1-12. [https://doi.org/10.1038/s41598-023-51107-y] [PMID]
26. Shan S, Lin L, Fang Q, Tian F, Guo D, Zhou Y, et al. Massage therapy significantly improves cancer-related fatigue in cancer patients: a meta-analysis of randomized controlled trials. Supportive Care in Cancer. 2023;31(8):1-16. [https://doi.org/10.1007/s00520-023-07926-w] [PMID]
27. Cai DC, Chen CY, Lo TY. Foot reflexology: recent research trends and prospects. Healthcare (Basel). 2022;11(1):1-18. [https://doi.org/10.3390/healthcare11010009] [PMID]
Send email to the article author
| Rights and permissions | |
 |
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |