European Journal of Oncology Nursing 32 (2018) 12–19

Contents lists available at ScienceDirect

European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

Reflexology in the management of chemotherapy induced peripheral MARK

neuropathy: A pilot randomized controlled trial
Seda Kurta,∗, Gulbeyaz Canb
a
Trakya University, Faculty of Health Sciences, Department of Medical Nursing, Edirne, Turkey
b
Florence Nightingale School of Nursing Istanbul University, Istanbul, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: The current experimental study aimed to evaluate the effectiveness of reflexology on the management
Peripheral neuropathy of symptoms and functions of chemotherapy-induced peripheral neuropathy (CIPN) in cancer patients.
Reflexology Method: This study was conducted as a randomized controlled trial in 60 patients (30 experimental and 30
Chemotherapy control patients) who had chemotherapy-induced Grade II-IV peripheral neuropathy complaints from July 2013
EORTC QLQCIPN-20
to November 2015. Data were collected using the patient identification form, European Organization for the
BPI
Research and Treatment of Cancer Quality of Life Questionnaire Chemotherapy-Induced Peripheral Neuropathy
(EORTC-CIPN-20) form, and BPI (used for related chemotherapy-induced peripheral neuropathy symptoms).
Results: The majority of the patients were being treated for gastrointestinal or breast cancer and were primarily
receiving Eloxatine- or taxane-based treatment. It was found that reflexology applications did not lead to dif-
ferences in either group in terms of peripheral neuropathy severity and incidence (p > 0.05) and only led to
improvement in sensory functions in the experimental group (p < 0.05).
Conclusions: It was determined that reflexology is not an effective method in the management of patients' ac-
tivity levels, walking ability etc. and motor, autonomic functions related CIPN, but reflexology is effective
method in the management of patients’ sensory functions related CIPN. Key Words: Peripheral neuropathy,
reflexology, chemotherapy, EORTC QLQ-CIPN-20, BPI.

1. Introduction patients with grad 3 or 4 peripheral neuropathies. The severity of the

Cancer is an important health problem in the World (WHO, 2016;
The Ministry of Health Turkey, 2016). Depending on type and stage of
the disease surgical treatment, chemotherapy, radiation therapy, hor-
mone therapy and targeted therapy can be the main treatment ap-
proaches for most of the patients but the side effects of the treatment
can deteriorate the patients’ quality of life. Fatigue, vomiting, diarrhea,
skin changes and peripheral neuropathy can be important side effects
for many patients (Kurt and Ünsar, 2011; Yıldırım, 2007).
Chemotherapy induced peripheral neuropathy (CIPN) can particu-
larly increase the risk of falls in patients by limiting the patient's phy-
sical functions (Can, 2008; Yıldırım, 2007; Saklı and Demir-Zencirci,
2013). This side effect frequently occurs in patients who received pla-
tinums (cisplatin, carboplatin and oxaliplatin), taxanes (docetaxel, ca-
bazitaxel), plant alkaloids (vinblastine, vincristine, etoposide) based
therapy (American Cancer Society, 2015; Park, 2014). CIPN is a dosage-
dependent toxicity and the incidence of CIPN is 10–100%. Sensory loss
or paresthesia interferes with activities of daily living and self-care, in
peripheral neuropathy can be reduced with dose reduction or cessation
of the medicine, in some patients. However, in others it may take a very
long time to relieve or may become permanent symptom (Argyriou,
2007; Kannarkata et al., 2008; Biedrzycki, 2010).
In the literature, many studies have been conducted to prevent or
manage chemotherapy realted peripheral neuropathy. However, the
efficiency of pharmacological approaches has been evaluated in most of
the studies. The positive effects of the reflexology, massage (Ihn Sook,
2006; Nicholas et al., 2017) and acupuncture (Ho and Roblew, 2011;
Nicholas et al., 2017) in management of the peripheral neuropathy
particularly have been demonstrated in diabetes and HIV related per-
ipheral neuropathy (Ihn Sook, 2006; Nicholas et al., 2017; Stephenson
et al., 2000; Yıldırım, 2007). In a limited number of studies conducted
with cancer patients, the efficiency of acupuncture (Donald et al., 2011;
Schroeder et al., 2012), exercises (Wampler et al., 2005) and massage
(Cunningham, 2011) was evaluated or submitted as case reports. The
results of these studies suggested that these approaches might be ef-
fective in management of CIPN.

∗
Corresponding author. Tel.: +90 284 2133042/2123; fax: +90 212 4400000/27002.
E-mail addresses: sedakurt81@gmail.com (S. Kurt), gulbeyaz@istanbul.edu.tr (G. Can).

https://doi.org/10.1016/j.ejon.2017.11.001
Received 12 July 2017; Received in revised form 30 October 2017; Accepted 1 November 2017
1462-3889/ © 2017 Elsevier Ltd. All rights reserved.
S. Kurt, G. Can European Journal of Oncology Nursing 32 (2018) 12–19

In a patient with stage III esophagealoesophagus adenocarcinoma,

the efficiency of massage (effleurage, petrissage) was reported in Grade
II peripheral neuropathy by the management of docetaxel-cisplatin. In
this case report it was stated that the grade II peripheral neuropathy
was downgraded to grade I at the end of the massage, because the in-
creased temperature accelerates the blood flow in that area
(Cunningham, 2011). In different case reports, it was also emphasized
that an exercise program might be effective in decreasing peripheral
neuropathy related to paraesthesia. Pain and balance scores were im-
Fig. 1. Foot Reflexology Chart (cervical and brain region) For Peripheral Neuropathy.
proved by an exercise program in this case (Wampler et al., 2005).
Acupuncture decreases the peripheral neuropathy related to analgesia
and improves the sleeping pattern (Donald et al., 2011) and cures the researcher), 20 min, twice a day, for six weeks. The standard care
peripheral neuropathy related to pain, paraesthesia and formation over protocol of the clinic was used for patients in the control group
the long term (Wong and Sagar, 2006). However, there are no rando- (n = 50). During the study, some of the patients did not complete the
mized controlled trials in which the efficiency of these approaches in questionnaires, some of them did not attend the reflexology massage or
CIPN management has been investigated. discontinued reflexology massage, and some of them did not attend the
Reflexology for neuropathy works with the help of chemical and second or third meetings. So, the study was completed with 60 patients
electrical stimulus that are sent by menas of nervous systems to balance (30 experimental and 30 control patients) (Fig. 2).
organs and parts in far reaching areas of the body. With neuropathy,
reflexology has a great option of gently activating the damaged nerve 2.2. Instruments and data collection
fibers to send and receive correct nervous signals. Through pressure
techniques, a stable rhythmic stimulus of information is sent and re- Three interviews were conducted with the patients: These include
ceived through the central nervous system. There is a certain im- the first meeting at the first sight, the second meeting is in the 3rd week
provement in the blood and lymph circulation in the body and in the and the third one is in the 6th week. The results of the study were
nerve response, and a general sense of wellbeing after the treatment of obtained in accordance with the Research Flow Chart (Fig. 3). At the
reflexology (Domenico, 2007; Tabur and Basaran, 2009; Soutar, 2012; first meeting, the patient identification form, NCI-CTCAE v4.0 toxicity
Tuğay, 2010; Wilhelm, 2003). There are only a few studies in the lit- cretaria, European Organization for the Research and Treatment of
erature evaluating peripheral neuropathic effects of reflexology, and Cancer Quality of Life Questionnaire Chemotherapy-Induced Peripheral
these studies have shown that reflexology reduces the severity of per- Neuropathy (EORTC QLQ-CIPN-20) quality of life form and the brief
ipheral neuropathy symptoms. (Se Young et al., 2012; Ben Horin et al., pain inventory (BPI) were completed and patients referred to physician
2017). Depending on these results, this study was planned to assess the for neurological examination. At the second visit the NCI-CTCAE v4.0
effect of reflexology in management of the CIPN. toxicity criteria, EORTC QLQ-CIPN-20 and BPI Scales were completed.
At the third visit the NCI-CTCAE v4.0 toxicity cretaria, EORTC QLQ-
1.1. Study hypothesis CIPN-20 and BPI Scales were completed and patients were referred to
physician for neurological examination again.
H1: Reflexology is an effective approach in the management of
chemotherapy-induced peripheral neuropathy. 2.2.1. Patient identification form
This form was prepared by the researcher and consists of two main
2. Sample and methods sections: the patient's personal characteristics (sex, age, education level,
occupation, marital status etc.) and the characteristics concerning the
2.1. Study design and participants disease and treatment (disease diagnosis, disease status, year of the
diagnosis, Eastern Cooperative Oncology Group ECOG performance
This pilot randomized controlled trial (RCT) study was conducted at score, received chemotherapy protocol, treatment cure etc.).
the outpatient chemotherapy unit in Trakya University Balkan
Oncology Hospital located in Edirne, Turkey, between July 2013 and NCI-CTCAE v4.0 toxicity criteria
November 2015.
The sample size for the study was calculated based on the pre- Toxicity
valence of the CIPN (10–100%). The acceptable value for α and β was Level
set as 0.05 and 0.20, respectively. The improvement in the peripheral
Grad 1 Mild; asymptomatic or mild symptoms; clinical or
neuropathy is expected to be 30% by reflexology application. The re-
diagnostic observations only; intervention not
quired sample was determined to be minimum 30 for each group.
indicated.
Patients who have grades 2–4 CIPN and have no any contraindications
Grad 2 Moderate; minimal, local or noninvasive intervention
for reflexology application were invited to the study. Patients were
indicated; limiting age-appropriate instrumental
excluded from the study if they had any condition that could sig-
activities of daily living
nificantly interfere with reflexology application, such as a bone or
Grad 3 Severe or medically significant but not immediately
vertebra metastasis.
life-threatening; hospitalization or prolongation of
Ninety-six patients attended to the study with simple sampling
hospitalization indicated; disabling; limiting self care
method. Patients were assigned to the experimental group (n = 46) and
activities of daily living
the control group (n = 50), using a randomization list prepared on the
Grad 4 Life-threatening consequences; urgent intervention
computer by the researcher. At the beginning of study verbally in-
indicated.
formation and training brochure about the CIPN were given to all pa-
Grad 5 Death related to Adverse Event
tients. The reflexology massage was applied to the experimental group.
The massage was applied on cervical area, located at the inner upper
side of each foot, by finger with worm-like movements and pressure
was apply on the brain area located under the big toe of both foot
(Fig. 1) by researcher (certified reflexologist) or relatives (educated by

13
S. Kurt, G. Can
2.2.2. European Organization for the Research and Treatment of Cancer
Quality of Life Questionnaire Chemotherapy-ınduced peripheral neuropathy
(EORTC-CIPN-20) form
The EORTC QLQ-CIPN-20 developed by Postma et al. is a 20-items
evaluation tool, which is used to assess the patients' functional re-
strictions caused by CIPN. The scale has three sub-dimensions, which
are sensory (formication, paraesthesia, pain, imbalance while seated or
standing, differentiating the temperature and hearing), motor (cramps,
writing, grasping small subjects, weakness) and autonomic (dizziness
after changing positions, seeing, erectile dysfunction). The 20 articles
use a Likert-type scale, and the answers are evaluated by giving points
as follows: not at all = 1, a little = 2, quite often = 3 and very
much = 4. High points obtained from these sections indicate more
symptoms and problems, and low points indicate fewer symptoms and
Fig. 3. Research flow chart.
14
European Journal of Oncology Nursing 32 (2018) 12–19
Fig. 2. Flow diagram.
problems. In calculating the points in all of the scales, the raw score is
obtained by calculating the mean of the articles in the scale's subgroup.
Raw score = RS = (I1 + I2 + …. + In)/n. Scale scores on all subscales
are calculated as on the EORTC QLQ-C30 symptom scale. When scaling
score is calculated, X100 formula is used (Postma, 2005). In 2015, the
Turkish validity and reliability study of the scale was performed by
Önsüz and Can. The Cronbach alpha reliability coefficient of the scale
was α = 0.87 and sub-dimensions (sensory, motor, autonomic) were
0.78, 0.85, −0.059, respectively (Önsüz, 2015).
2.2.3. Brief pain inventory (BPI)
The BPI developed by Cleenlad et al. This BPI was confirmed in a
large national study conducted in the U.S. by the Eastern Cooperative
Oncology Group. The Cronbach alpha reliability coefficient of the scale
S. Kurt, G. Can
was α ranging from 0.80 to 0.87 for the four pain severity items and
from 0.89 to 0.92 for the seven interference items. Subsequent data
from studies of cancer patients in many countries and many languages
have demonstrated high internal consistency and the robust nature the
BPI (Cleeland, 2009). Also, BPI was tested for validity and reliability on
Turkish by Dicle et al. and the cronbach alpha reliability coefficient of
the scale was α = 0.79 (Dicle et al., 2009). The BPI questionnaire is an
easily conducted evaluation method used for pain assessment and re-
lated functions (general activity, walking ability, normal working ac-
tivities, relations with other people, sleeping and the enjoyment of life).
It includes a simple evaluation scale from zero to ten, which is easy to
understand and to translate into different languages. In the BPI, the
lowest pain score = 0, and the highest pain score = 10. The inventory
evaluates the severity of the pain, its location, medical treatments for
the pain and its effect on daily functions; it examines how much of a
degradation is seen over the previous 24 h or during the previous week.
Answering all of the questions takes only five to ten minutes (Cleeland,
and Ryan, 1994).
2.3. Ethical considerations
In order to be able to carry out the study in Trakya University
Balkan Oncology Hospital, an approval from the Trakya University
School of Medicine Ethics Commission of Non-invasive Clinical Trials
(IRB file no: TUTF-GOKAEK2013/123) and Trakya University Health
Center of Medical Research and Practice were necessary. For each pa-
tient both written and oral consent was taken.
2.4. Statistical analysis
Data was analysed using descriptive (percentage, mean) and com-
parative (chi-squared analysis, t-test, Mann-Whitney U test and the
Wilcoxon signed ranks test) statistics. Numerical results were expressed
as mean SD, and categorical results were expressed as percentages.
Differences between groups were assessed by the ManneWhitney U test.
Comparison of the before and after values of the symptom scores was
assessed by the Wilcoxon signed rank test. The chi-square test was used
to compare differences in categorical variables among the groups. A p-
value < 0.05 was considered statistically significant. Statistica 22.0
(StatSoft Inc. Tulsa, OK, USA) statistical software was used for statis-
tical analyses.
3. Results
3.1. Patients’ demographic and clinical characteristics
When the personal characteristics of the patients in the study group
were examined, it was found that the mean age of the experimental and
control groups, which showed similarities regarding the personal
characteristics, was 58; and besides, in both experimental and control
groups, half of the patients were male. Almost half of the patients in the
experimental group were self-employed/salaried employees, whereas,
in the control group, the patients were pensioners/housewives. It was
found out that in both the experimental and control groups, most of the
patients were married; about one-third of the patients were primary
school graduates. All of the patients in the experimental group and most
of the patients in the control group stated that they stopped working
because of the disease (Table 1). Considering the expected values, it
was determined that there was no statistical difference between the
groups, and moreover they were similar.
When the characteristics of the disease and the treatment were
analysed, it was determined that, in accordance with the expected va-
lues, there was no statistical difference between the two groups, and
that experimental and control groups were similar. Looking at the
disease diagnosis, it was detected that patients were mostly diagnosed
with breast cancer and gastrointestinal stromal tumours (GIST). When
15
European Journal of Oncology Nursing 32 (2018) 12–19
the characteristics of the chemotherapy that the patients were currently
receiving, were analysed, it was determined that the patients were
generally receiving Eloxatine- and taxane-based chemotherapy cures
and the amount of the average chemotherapy cure that they were re-
ceiving was 7. It was also found out that the Eastern Cooperative
Oncology Group (ECOG) performance score of all the patients was two
(Table 1).
Analysing the patients' characteristics related to peripheral neuro-
pathy, it was found that in both groups about three-quarters of the
patients’ peripheral neuropathy severity was Grade 2, and that this
condition was continuous in most of the patients (Table 1). In ac-
cordance with the expected values, no statistical difference between the
two groups was found, and it was found that they were similar.
3.2. The effect of reflexology on peripheral neuropathy symptoms
It was determined that reflexology application improved the activity
level, walking ability, normal working activities, relations with other
people, sleep pattern, enjoyment of life and sensory, motor and auto-
nomic functions of the patients in the experimental group. This im-
provement was found to be statistically significant (p > 0.001,
p = 0.003, p = 0.001, p = 0.002, p = 0.017 and p = 0.001, re-
spectively; however, it was determined that there was no statistically
significant difference between the groups, at that it was not an effective
approach (p > 0.05) (Table 2).
3.3. The effect of reflexology on quality of life functions related CIPN
Average score of the EORTC-CIPN-20 scale was shown in Table 3.
When reflexology's effect on the quality of life regarding CIPN was
examined, it was detected that reflexology application improved the
sensory, motor and autonomic functions of the patients in the experi-
mental group, and that this improvement was statistically significant
(p > 0.001, p = 0.002 and p = 0.012, respectively). However, it was
also found that except for the improvement in the sensory functions
after the 3rd interview (p = 0.024), reflexology showed no statistically
significant difference between these two groups in other areas, and that
it was not an effective approach (p > 0.05) (Table 3).
4. Discussion
Peripheral neuropathy is a set of symptoms concerning the per-
ipheric neurons related to brain and spinal cord damage. Peripheric
neurons take charge of enabling the movement of the limbs, bowel and
bladder etc. (American Cancer Society, 2015). CIPN typically develops
depending on the platinums, taxanes, plant alkaloids and dosage
(American Cancer Society, 2015; Park, 2014). Although the mechanism
of the CIPN cannot be explained, it is known that it emerges through
blocking axonal transmission causing a degeneration on the sensory
fibres and small fibre loss on the epidermal layer by directly affecting
the spinal ganglions and peripheral neurons, as well as by stopping the
function of mitochondria or directly affecting the DNA (Can, 2008;
Saklı and Demir-Zencirci, 2013; Yıldırım, 2007). The initial damage of
chemotherapy generally occurs on sensory axons. Then, it spreads to-
wards other axons and their myelin sheaths, respectively. Dysfunction
of the neurons' action potential (synapsis) as a result of sensory axon
damage is the most common finding (Biedrzycki, 2010). We come
across peripheral neuropathy not only because of the effects of che-
motherapeutic medicines but also because of medical disorders, such as
diabetes, HIV etc., which affect the neurological system (American
Cancer Society, 2015). Diabetic neuropathy develops in the case of the
destruction of a nerve fibre, which is exposed to an ill controlled, long-
lasting, and poor glycaemic control, and when there is an imbalance
during its restoration. Nerve injury mostly affects autonomic and distal
sensory fibres and usually recovers swiftly when the glycaemia is
brought under control (Ünal et al., 2015). Various peripheric
S. Kurt, G. Can European Journal of Oncology Nursing 32 (2018) 12–19

Table 1
Homogeneity test of general, diagnostic and peripheral neuropathic characteristics between experimental and control groups before the intervention.

Experimental (n = 30) Control (n = 30)

Age X ± sd X ± sd t p

58.33 11.24 57.86 10.56 0.166 0.869

n % n % χ 2
p

Gender
Male 16(16) 53.3 16(16) 53.3 0.0 1.0
Female 14(14) 46.7 14(14) 46.7

Job
Self-Employed/Salaried Workers 16(13.5) 53.3 11(13.5) 36.7 1.684 0.194
Retired/housewife 14(16.5) 46.7 19(16.5) 63.3

Marital Status
Married 27(27.5) 90.0 28(27.5) 93.3 0.218 1.0a
Single/Widowed 3(2.5) 10.0 2(2.5) 6.7

Education
Illiterate/Literacy 3(2.5) 10.0 2(2.5) 6.7 0.476 0.788a
Primary school 20(19.5) 66.7 19(19.5) 63.3
Secondary and higher 7(8.0) 23.3 9(8.0) 30.0

Working status
Working 0(2.0) 0.0 4(2.0) 13.3 4.286 0.112a
It can not work because of present illness 30(28.0) 100.0 26(28.0) 86.7

Cancer Diagnosis
Breast 5(6.0) 16.7 7(6.0) 23.3 1.090 0.580
Digestive system cancers 19(17.0) 63.3 15(17.0) 50.0
Other Cancer 6(7.0) 20.0 8(7.0) 26.7

Chemotherapy protocol
Eloxatin-based 13(10.5) 43.3 8(10.5) 26.7 2.463 0.651a
Taxan-based 7(8.5) 23.3 10(8.5) 33.3
Platin-based 3(2.5) 10.0 2(2.5) 6.7
Taxan-Platin-based 3(3.5) 10.0 4(3.5) 13.3
Fluoracil-based 4(5.0) 13.3 6(5.0) 20.0

Peripheral neuropathy grade

Grade 2 23(23.5) 76.7 24(23.5) 80.0 0.098 0.754
Grade 3 and 4b 7(6.5) 23.3 6(6.5) 20.0

Peripheral neuropathy duration

One week after treatment 10(9.5) 33.3 9(9.5) 30.0 0.077 0.781
Consistently 20(20.5) 66.7 21(20.5) 70.0

x ± sd x ± sd zMWU p

Total number of chemotherapy cure 7.37 3.42 6.96 3.67 −0.541 0.589

a
Exact x2 value is used because minimum value < 3.
b
Grade 3 and Grade 4 was analyzed by combining options.

neuropathy conditions can also develop in different phases of HIV in-
fection. Chronic demyelinating polyradiculoneuropathy usually de-
velops in the early or medium phases of a disease and reveals itself with
symptoms such as formication, paraesthesia or irritancy. In the per-
ipheral neuropathy symptom, which occurs with different physio-pa-
thological solutions as a result of different clinical conditions, in order
to provide a recovery by means of reflexology, pressure is applied on
the reflex points by rubbing, patting and squeezing, and with that
pressure the energy is balanced, the body's self-treatment mechanism is
triggered and this gives the body a physiological relief. With the special
rubbing movements, the energy, which is blocked in some parts of the
body, is set free and the body's self-healing power is activated. The
pressure applied on these reflex points via hand and finger techniques
especially diminishes the stress and causes physiological changes in the
body (Domenico, 2007; Köksoy, 2008; Kurt and Can, 2013; Tabur and
Basaran, 2009; Soutar, 2012; Tuğay, 2010; Wilhelm, 2003). Con-
cordantly, in some studies carried out with the participation of the
patients with peripheral neuropathy problems caused by different
physio-pathological factors, it was stated that reflexology application
might be an effective approach in the management of this problem (Ihn
Sook, 2006; Nicholas et al., 2017).
Degradation was detected in the peripheral neuropathy symptoms
(especially formication and pain) of diabetic patients who performed
reflexology for six weeks on their own (Ihn Sook, 2006). In another
study carried out with a randomized controlled group of diabetic pa-
tients, it was stated that reflexology was an effective approach in the
management of diabetic peripheral neuropathy, and that the severity of
neuropathy decreased from 7.8 to 3.0 in the group receiving reflexology
and from 7.0 to 6.0 in the control group (Dalal et al., 2014). In another
study, in which alternative treatments were evaluated for the man-
agement of peripheral neuropathy in patients with an HIV/AIDS diag-
nosis, it was determined that, with a value of 7.53, reflexology had the
greatest effect among the other alternative approaches (ex-
ercises = 5.93, massage = 6.84 and acupuncture = 6.81) (Nicholas

16
S. Kurt, G. Can European Journal of Oncology Nursing 32 (2018) 12–19

Table 2
The effect of refloxology on peripheral neuropathy symptoms.

1st Interwiev (I1) 2nd Interwiev (I2) 3rd Interwiev (I3) Periferan Neuropathy Score
I1 vs I3

X ± sd X ± sd X ± sd Decrease at I3 Increase at I3 Ties at I3 za p

(n) (n) (n)

General Activity Experimental 4.86 2.62 3.56 2.23 2.93 2.49 22 4 4 −3.61 < 0.001
Control 4.03 2.61 3.76 2.45 3.36 2.26 16 11 3 −1.61 0.11
zMWU=-1.02 zMWU=-0.29 zMWU=-1.03
p = 0.31 p = 0.78 p = 0.30
Walking ability Experimental 4.73 2.93 3.26 2.11 2.86 2.47 20 3 7 −3.02 0.003
Control 3.73 2.50 4.00 2.43 3.60 2.38 9 11 10 −0.26 0.79
zMWU=-1.36 zMWU=-1.20 zMWU=-1.38 –
p = 0.18 p = 0.23 p = 0.17
Normal Work Experimental 4.90 2.90 3.40 2.44 2.93 2.67 21 4 5 −3.34 0.001
Control 3.66 2.98 3.73 2.54 3.13 2.64 13 8 9 −1.17 0.24
zMWU=-1.63 zMWU=-0.55 zMWU=-0.30 –
p = 0.10 p = 0.58 p = 0.76
Relations with other Experimental 2.33 2.46 1.73 2.19 1.16 2.22 18 2 10 −3.07 0.002
people Control 1.80 2.36 1.70 2.08 1.73 2.33 10 7 13 −0.31 0.76
zMWU=-1.09 zMWU=-0.17 zMWU=-1.10
p = 0.28 p = 0.86 p = 0.27
Sleep Experimental 3.13 3.69 2.16 2.96 1.90 2.46 14 4 12 −2.39 0.017
Control 3.33 3.59 3.16 3.43 2.70 3.41 11 6 13 −1.34 0.18
zMWU=-0.33 zMWU=-1.54 zMWU=-0.65 –
p = 0.74 p = 0.12 p = 0.52
Enjoyment of life Experimental 4.20 3.17 2.66 2.86 2.13 2.84 20 3 7 −3.32 0.001
Control 2.76 2.77 2.90 2.94 2.86 3.02 11 10 9 −0.11 0.92
zMWU=-1.9 zMWU=-0.36 zMWU=-1.12 –
p = 0.06 p = 0.72 p = 0.26

p < 0.05 results were reported as bold.

a
Wilcoxon Signed Ranks Test.

et al., 2017). In a randomized controlled study carried out with cancer
patients, it was found that experimental group felt the peripheral
neuropathy less than the control group (Se Young et al., 2012).
In other studies, conducted with other complementary treatments
having similar effects as reflexology, similar results were obtained. In
Arıkan's study, which evaluated the efficiency of massage, in one of the
other complementary treatments on colorectal cancer patients with
peripheral neuropathy, it was seen that massage decreased peripheric
neuropathy complaints and other symptoms (pain, exhaustion, sleep-
lessness) (Arıkan, 2013). In a case study, in which the effect of a manual
therapy (massage) on a 45-year-old male patient with CIPN who had no
diabetes or any neurological disorder and who received a docetaxel,
cisplatin, 5-fluorouracil treatment was evaluated, the patients received
three sessions of massage per week for six weeks, and it was reported
that the formication, paraesthesia and pain symptoms in all of the pa-
tients' extremities dramatically decreased and that all of the extremities
became warm (Cunningham, 2011). In a case study in which the effects
of acupuncture on a 54-year-old female patient with Grade 2 peripheral
neuropathy who was receiving a low dosage gabapentin treatment as a
result of the acupuncture once a week, it was detected that patient's
pain level dropped from 4 to 1 and that it was an effective approach in
low dosage gabapentin- and paclitaxel-related peripheral neuropathy. It
was also emphasized that it might prevent the need to decrease the
chemotherapy dosage (Bhatnagar et al., 2013).
In a study, in which the patients with gynaecological cancer, CIPN's
effect on the quality of life was examined, it was found that the patients'
neuropathy score was 14.3 ± 7.9, quality of life score was
64.8 ± 16.4 and that disease diagnosis, existence of diabetes,

Table 3
The effct of reflexology on quality of life related CIPN.

1st Interwiev (I1) 2nd Interwiev (I2) 3rd Interwiev (I3) Periferan Neuropathy Score
I1 vs I3

X ± sd X ± sd X ± sd Decrease at I3 Increase at I3 Ties at I3 za p

(n) (n) (n)

Sensory Function Experimental 37.77 19.46 26.54 13.58 22.83 16.50 24 3 3 −3.774 < 0.001
Control 40.49 21.87 37.53 20.02 34.44 20.77 16 8 6 −1.045 0.3
zMWU=-0.28 zMWU=-1.81 zMWU=-2.26
p = 0.78 p = 0.07 p = 0.024
Motor Function Experimental 24.46 15.57 16.40 13.03 16.17 20.91 25 3 2 −3.079 0.002
Control 26.28 23.09 24.68 19.66 19.02 18.74 13 7 10 −1.570 0.12
zMWU=-0.20 zMWU=-1.51 zMWU=-0.72
p = 0.84 p = 0.13 p = 0.47
Autonomic Experimental 29.81 20.76 24.81 18.43 20.55 18.80 17 4 9 −2.523 0.012
Function Control 36.48 24.91 33.33 27.37 28.33 27.38 9 4 17 −1.839 0.07
zMWU=-0.62 zMWU=-0.81 zMWU=-0.98
p = 0.54 p = 0.42 p = 0.33

p < 0.05 results were reported as bold.

a
Wilcoxon Signed Ranks Test.

17
S. Kurt, G. Can
uneasiness with the household chores and the number of che-
motherapies affected the neuropathy score. In the same study, a nega-
tive relation was found between the number of chemotherapies and the
quality of life, and it was reported that neuropathy affected the quality
of life independently (Ju-Hyeon et al., 2013). Similar results were ob-
tained in other studies carried out with other complementary treat-
ments, which had similar effects to those of reflexology. In one study, in
which the effect of massage on peripheric neuropathy and the quality of
life was evaluated, massage was found to have a positive effect on the
quality of life (Arıkan, 2013). In another study, which discussed the
effect of massage on the symptoms and the quality of life in patients
with breast cancer, it was detected that massage affected the total score
of the quality of life positively and that it reduced chemotherapy-in-
duced physical and psychological symptoms (Ovayolu et al., 2013). In a
case report, in which exercise was evaluated in breast cancer patients
with CIPN, it was found that exercise was successful in relieving per-
ipheral neuropathy and pain and that it improved the quality of life
(Wampler et al., 2005). In a randomized controlled study, in which the
effect of reflexology on peripheral neuropathy and the quality of life in
patients with cancer was evaluated, the experimental group felt the
effects of peripheral neuropathy less than the control group (Se Young
et al., 2012). Even if it was detected in our study that reflexology im-
proved the patients' activity levels, walking abilities, normal working
activities, relations with other people, sleeping patterns and enjoyment
of life, as well as sensory, motor and autonomic functions, in the ex-
perimental group, it provided no statistically significant difference be-
tween these groups except for the improvement in the sensory func-
tions. In our study, patients in the experimental group shared
similarities with the general literature, and it is supported that reflex-
ology application relieves the severity of peripheral neuropathy. At the
same time, although there was no significant difference in quality of life
or motor and autonomic symptoms, a decrease was detected in the
severity of sensory function symptoms (formication, paraesthesia,
stabbing or burning pain). This result is thought to be due to the variety
of the physio-pathological processes, which is affected in a different
way from other medical disorders (diabetes, HIV etc.). Especially in
diabetes, the fact that peripheral neuropathy can be controlled more
swiftly with a well applied glycaemic control might give better results
than CIPN. For this reason, maintaining reflexology application over a
longer term is thought to be important to obtain significant results.
5. Limitations of the study
The limitations of the research were the situations in which the
patients did not precisely answer or want to answer the survey ques-
tions during the chemotherapy; when the patients in the experimental
group skipped the practices; when they were not available for the
second evaluation; and when there were disruptions in the commu-
nication and practices due to deterioration caused by the disease during
the course of the study.
6. Conclusion and recommendations
In this study, which was carried out with the aim of evaluating the
effect of reflexology on the management of peripheral neuropathy
symptoms, it was determined that reflexology was an effective ap-
proach in improving patients' activity levels, walking ability, normal
working activities, relations with other people, sleeping patterns and
enjoyment of life, as well as sensory, motor and autonomic functions in
the experimental group. However, no statistically significant difference
was found between the two groups regarding its effectiveness on im-
proving the patients' activity levels, walking ability, normal working
activities, relations with other people, sleeping patterns and enjoyment
of life related CIPN. Also no statistically significant difference was
found between the two groups regarding its effectiveness on improving
the patients’ quality of life functions (motor and autonomic functions)
18
European Journal of Oncology Nursing 32 (2018) 12–19
related CIPN, but statistically significant difference was found in the
sensory functions related CIPN. According to these data, compared with
the early applications, reflexology increases the level of the quality of
life functions related CIPN in a positive way as long as it is continued;
therefore, reflexology can be recommended to the patients.
Conflict of interest
The authors declare no conflict of interest.
References
American Cancer Society, 2015. Peripheral neuropathy caused by chemotherapy, 2015.
http://www.cancer.org/acs/groups/cid/documents/webcontent/002908-pdf.pdf,
Accessed date: 10 October 2015.
Argyriou, A.A., 2007. Incidence ve characteristics of peripheral neuropathy during ox-
aliplatin-based chemotherapy for metastatic colon cancer. Acta Oncol. 46,
1131–1137.
Arıkan, F., 2013. Effect of massage therapy on peripheral neuropathy and life quality of
colorectal cancer with patient receiving (Kemoterapi Alan Kolorektal Kanseri
Hastalarına Masajın Periferik Nöropati Ve Yaşam Kalitesi Üzerine Etkisi). PhD
Thesis. Erciyes Üniversitesi Sağlık Bilimleri Enstitüsü Doktora Tezi, Kayseri.
Ben-Horin, I., Kahan, P., Ryvo, L., Inbar, M., Lev-Ari, S., Geva, R., 2017. Acupuncture and
reflexology for chemotherapy-induced peripheral neuropathy in breast cancer.
Integr. Cancer Ther. 16 (3), 258–262.
Bhatnagar, B., Pelser, C., Gilmore, S., Tait, N., Bao, T., 2013. Acupuncture and low dose
gabapentin effectively treat paclitaxel induced peripheral neuropathy ve prevent
chemotherapy dose reduction. Altern. ve Integr. Med. 2 (6), 1–3.
Biedrzycki, B.A., 2010. Peripheral neuropathy. In: Brown, C.G. (Ed.), A Guide to
Oncology Symptom Management. ONS Pittsburgh, Pennsylvania, pp. 405–419.
Can, G., 2008. neurotoxicity (Nörotoksisite). Onkoloji Hemşireliğinde Kanıta Dayalı
Semptom Yönetimi Konsensus'07 In: Can, G., Enç, N., Akaya, S. (Eds.), Evidence-
Based Symptom Management in Oncology Nursing’07. Mavi İletişim Danışmanlık AŞ
Medikal Yayıncılık, İstanbul, pp. 157–169.
Cleeland, C.S., Ryan, K.M., 1994. Pain assessment: global use of the brief pain inventory.
Ann. Acad. Med. Singap. 23, 129–138.
Cleeland, C.S., 2009. The brief pain inventory user guide – online. http://www.
anesthesiologie.nl/uploads/kwaliteit/4_-_Toelichting_BPI.pdf, Accessed date: 17
October 2017.
Cunningham, J.E., 2011. Case report of a patient with chemotherapy-induced peripheral
neuropathy treated with manual therapy (massage). Support Care Cancer 19,
1473–1476.
Dalal, K., Maran, V.B., Pveey, R.M., Tripathi, M., 2014. Determination of Efficacy of
Reflexology in Managing Patients with Diabetic Neuropathy: a Randomized
Controlled Clinical Trial, Evidence-based Complementary Ve Alternative Medicine.
Jan (9). https://doi.org/10.1155/2014/843036.
Dicle, S., Karayurt, O., Dirimese, E., 2009. Validation of the Turkish version of the brief
pain inventory in surgery. Pain Manag. Nurs. 10 (2), 107–113.
Domenico, G.D., 2007. Beard's Massage Principle Ve Practice of Soft Tissue Manipulation.
Soft Tissue Manipulation in Complementary/alternative Medicine in Texas. Saunders
Elsevier, pp. 294–309.
Donald, G.K., Tobin, I., Stringer, J., 2011. Evaluation of acupuncture in the management
of chemotherapy-induced peripheral neuropath. Acupunct. Med. 29 (3), 230–233.
Ho, E.Y., Roblew, J.S., 2011. Cultural resources for health participation: examining bio-
medicine, acupuncture, and massage therapy for HIV-related peripheral neuropathy.
Health Commun. 26, 135–146.
Ihn-Sook, J., 2006. Effect of self-foot reflexology on peripheral blood circulation ve
peripheral neuropathy in patients with diabetes mellitus. J. Korean Acad. Nurs. 13
(2), 225–234.
Ju-Hyeon, J., Ju-Hee, N., Gi-Suk, K., Young-Eun, L., Sun-Young, Y., Hyun-Ju, L., Yu-Mi,
S., Young-Sun, L., 2013. Characteristics ve quality of life in gynecologic cancer pa-
tients with chemotherapy-induced peripheral neuropathy. Korean J. Women Health
Nurs. 19 (4), 201–210.
Kannarkata, G., Lasher, E.E., Schiff, D., 2008. neurologic complications of chemother-
apeutic agents (Kemoterapi ajanlarının nörolojik komplikasyonları). Curr. Opin.
Neurology 2, 719–725.
Köksoy, S., 2008. The knowledge level and using of complementary and alternative
therapies of the doctors, nurses and midwife who working at hospitals (Yataklı Sağlık
Kuruluşlarında Çalışan Doktor, Hemşire Ve Ebelerin Tamamlayıcı Ve Alternatif
Tedavi Yöntemlerini Bilme Ve Kullanma Durumları). Master’s Thesis. Mersin
Üniversitesi Sağlık Bilimleri Enstitüsü Hemşirelik Anabilim Dalı Yüksek Lisans Tezi,
Mersin.
Kurt, S., Can, G., 2013. Reflexology and application areas (Refleksoloji ve kullanım
alanları). Sağlıkla Derg. 3, 54–55.
Kurt, S., Ünsar, S., 2011. Assessment of symptom control in patients with cancer in
Northwestern Turkey. Eur. J. Oncol. Nurs. 15, 137–144.
Nicholas, P.K., Kemppainen, J.K., Canaval, G.E., Corless, I.B., Sefcik, E.F., Nokes, K.M.,
2017. Symptom management ve self-care for peripheral neuropath in HIV/AIDS.
AIDS Care 19 (2), 179–189.
Önsüz, Ü., 2015. efficiency of the interventions practiced by patients in the management
of peripheral neuropathy occurring in cancer patients administered with taxan-based
treatment (Taksan Bazlı Tedavi Alan Kanser Hastalarında Oluşan Periferal
S. Kurt, G. Can
Nöropatinin Yönetiminde Hastaların Uyguladığı Girişimlerin Etkinliği). Master’s
Thesis. İstanbul Üniversitesi. Sağlık Bilimleri Enstitüsü Hemşirelik Anabilim Dalı İç
Hastalıkları Hemşireliği Yüksek Lisans Tezi, İstanbul.
Ovayolu, Ö., Seviğ, Ü., Ovayolu, N., Sevinç, A., 2013. The effect of aromatherapy ve
massage administered in different ways to women with breast cancer on their
symptoms ve quality of life. Int. J. Nurs. Pract. 20, 1–10.
Park, H.J., 2014. Chemotherapy induced peripheral neuropathic pain. Korean J.
Anesthesiol. 67 (1), 4–7.
Postma, T.J., 2005. The development of an EORTC quality of life questionnaire to assess
chemotherapy-induced peripheral neuropathy: the QLQ-CIPN20. Eur. J. Cancer 11,
1135–1139.
Saklı, K., Demir-Zencirci, A., 2013. Nursing interventions of chemotherapy induced
peripheral neuropathy and neuropathic pain in patients receiving taxanes and pla-
tino: a literature review (Taksan ve platin alan hastalarda periferal nöropati ve
nöropatik ağrıya yönelik hemşirelik girişimleri: sistematik derleme). Hemşirelikte
Araştırma Geliştirme Derg. 1, 61–73.
Schroeder, S., Meyer-Hamme, G., Epplee, S., 2012. Acupuncture for chemotherapy-in-
duced peripheral neuropath (CIPN): a pilot study using neurography. Acupunct. Med.
30, 4–7.
Se Young, L., Yun, H.H., Oh Nam, O., Eun, J.K., In, G.K., Moon Sook, H., Myung Sook, C.,
2012. The effects of foot reflexology on peripheral neuropathy, symptom distress,
anxiety and depression in cancer patients treated with oxaliplatin. Asian Oncol. Nurs.
12 (4), 305–313.
Soutar, G., 2012. Reflexology for Hands and Feet (Eller ve ayaklar için refleksoloji).
19
European Journal of Oncology Nursing 32 (2018) 12–19
Translation, Evyapan T.. third ed. Arkadaş Yayınevi, Ankara, pp. 8–26.
Stephenson, N., Weinrich, S.P., Tavakoli, A.S., 2000. The effects of foot reflexology on
anxiety ve pain in patients with breast ve lung cancer. Oncol. Nurs. Forum 27 (1),
67–72.
Tabur, H., Basaran, E.B.Z., 2009. Introduction to Reflexology (Refleksoloji’ye giriş). first
ed. Kitapdostu Yayınları, İzmir, pp. 11–140.
The Ministry of Health of Turkey, 2016. Cancer of the war department, cancer statistics
2016. http://www.saglik.gov.tr/, Accessed date: 2 February 2016. http://kanser.
gov.tr/daire-faaliyetleri/kanser-istatistikleri.html.pdf.
Tuğay, N., 2010. Massage techniques (Masaj teknikleri). In: İnci, Y. (Ed.), Refleksoloji
(Reflexology). Öz Baran Ofset, Ankara, pp. 184–193.
Ünal, E., Akan, O., Üçler, S., 2015. Effects of diabetes mellitus on neurological disorders
(Diyabet ve nörolojik hastalıklar). Ok Meydanı Tıp Derg. 31, 45–51.
Wampler, M.A., Hamolsky, D., Hamel, K., Melisko, M., Topp, K.S., 2005. Case report:
painful peripheral neuropathy following treatment with docetaxel for breast cancer.
Clin. J. Oncol. Nurs. 9 (2), 189–193.
Wilhelm, Z.A., 2003. Reflexology (Refleksoloji). Kitap Matbaacılık, İstanbul.
Wong, R., Sagar, S., 2006. Acupuncture treatment for chemotherapy-induced peripheral
neuropathy – a case series. Acupunct. Med. 24 (2), 87–91.
World Health Organization Programmes and Projects, 2016. Cancer (WHO), World cancer
report 2016. http://www.who.int/cancer/en/, Accessed date: 10 February 2016.
Yıldırım, Y.K., 2007. neurotoxicity (Nörotoksisite). Onkoloji Hemşireliğinde Kanıta
Dayalı Semptom Yönetimi In: Can, G. (Ed.), Evidence-Based Symptom Management
in Oncology Nursing. 3P Pharma Publication Planing, İstanbul, pp. 81–99.