Reflexology and sub-fertility

I had never come across the baffling concept of “reproductive reflexology” until a local practitioner had a leaflet popped through my letterbox.  They rather fetchingly style themselves “foothold reflexology”.  The leaflet’s major theme is to suggest that reflexology can help with pregnancy and sub-fertility.

Given that a glorified foot massage is massively unlikely to offer help beyond relaxing someone and generally making them feel nice, I thought that this was worth a bit of investigation.  My main concern with this pitch is that issues around fertility can be profoundly distressing.  Though I am sure that this reflexologist is sincere and well-meaning, peddling false hope is cruel.

The leaflet makes no explicit claims, but associates fertility and reflexology.  The implication is clear: reflexology can help with sub-fertility.  To quote the relevant statement:

“What’s on offer … Pregnancy and Sub-Fertility Reflexology”

A little background

In their book Trick or Treatment, Singh and Ernst (2008) provide this helpful description of reflexology.

“Manual massages of the feet are usually experienced as relaxing and it is therefore not surprising that they were used in various ancient cultures.  But reflexology is different.  It is based on assumptions by William Fitzgerald who, in the early twentieth century, postulated that the body is divided into ten vertical zones, each represented by part of the foot.  Fitzgerald and his followers developed maps of the sole of the feet showing which areas correspond to which inner organs.

Reflexologists take a brief medical history and then manually investigate the foot.  If they feel a resistance in one area they are likely to diagnose a problem with the corresponding organ.  The therapy then consists of a high-pressure massage at this point, which is believed to repair the function of the troubled organ and ultimately to improve the patient’s health or prevent illness.”

So, reflexology is a practice which claims to offer both diagnosis and treatment of a range of ailments via a foot massage targeted at specific areas of the foot.  Practitioners assert that various regions of the foot control the function of specific organs.  This claim has absolutely no physiological basis.  As Singh and Ernst (2008) go on to say:

“The postulated reflex pathways between a certain area of the foot and an inner organ do not exist … Hence the technique is not biologically plausible.”

So the prior probability of reflexology being effective as a diagnostic or treatment tool in any particular health condition is vanishingly small.  That’s not to say that some short-term benefit cannot arise from the profound psychological influence of being touched by someone who wants to help you.  It’s also possible to imagine that some might find this kind of foot massage relaxing, and that might help them feel a bit better at times.

However, it’s very unlikely that fiddling with someone’s feet is likely to be a good method of diagnosing health problems.  So, when White et al (2000) tested the diagnostic skills of two experienced reflexologists it’s not surprising that their results, “… do not suggest that reflexology techniques are a valid method of diagnosis”.

Furthermore, like acupuncture, the locations selected for attention are irrelevant: Williamson et al. (2002) found that, “Foot reflexology was not shown to be more effective than non-specific foot massage in the treatment of psychological symptoms occurring during the menopause.”

This also fits in with Sigh and Ernst’s (2008) observation that, “… several different versions of reflexology maps exist – reflexologists cannot even agree among themselves how to apply the treatment.”

So, it’s basically not biologically plausible; doesn’t seem to work as a diagnostic tool and it doesn’t matter where the foot is massaged; but

… Is there any evidence that it works?

Setting aside, for the moment, concerns about the basic biological plausibility of the claims made for reflexology: is there any evidence that it works?  When I say “works” I mean, of course: do sufficiently large well-designed studies consistently show an effect for the intervention that is significantly (statistically and clinically) larger than any change seen in a well-matched control group?

First, turning to the Cochrane Library and searching for “reflexology and fertility” returned no results.  Searching for “reflexology” alone revealed six relevant Cochrane Reviews:

Bamigboye and Smyth (2007) examined the evidence for the treatment of varicose veins and leg oedema in pregnancy.  One small study (Mollart, 2003) enrolled 55 women with oedema in pregnancy.  They were allocated to either two different types of reflexology or 15 minute periods of rest, as a control.  It appeared to show some benefit for reflexology, compared to rest.  The authors of the review concluded that there was, “… insufficient data to be able to assess benefits and harms, but [it] looked promising …” This is certainly not evidence to support the effectiveness of reflexology.

Smith et al (2006) looked at the evidence for various CAM interventions for pain management in labour.  No evidence was adduced for reflexology.

Hansen, Jørgensen and Ørtenblad (2006) mention reflexology in their review of, “Massage and touch for dementia”.  However the review found no data of sufficient quality to assess reflexology.

Furlan et al (2008) reviewed, “Massage for low-back pain” and included a single trial of reflexology (Poole, Glenn and Murphy, 2007).  This concluded that, “the current study does not indicate that adding reflexology to usual GP care for the management of [chronic low back pain] is any more effective than usual GP care alone.” This was because their, “pragmatic randomised controlled trial” of 243 patients showed no significant difference between reflexology, relaxation, or “usual care”.

Harvey et al (2007) reviewed, “Nasal saline irrigations for the symptoms of chronic rhinosinusitis”.  This uncovered a single study comparing nasal saline irrigations against a reflexology “control treatment”. (Heatley et al, 2001)  This work found that saline irrigations did not improve disease specific quality of life scores more than the reflexology “control treatment”.

However, some improvement was seen with all the interventions.  Although the authors interpreted this as meaning that all the interventions were, “equally efficacious” the experimental design leaves open the stronger possibility that the two types of saline irrigation and the reflexology “control” were equally inefficacious.

As for the experimental design, the choice of reflexology as a “control treatment” is pretty odd.  Whilst nasal irrigation is a plausible intervention for rhinosinusitis, reflexology is not.  Unsurprisingly, neither is it a standard treatment for this condition.  This would imply that the authors expected it to be a therapeutically inert “placebo”.  Therefore making it into a post-hoc “treatment” so that the study can be seen as “positive”, is just not right.  If reflexology was actually included as a “treatment” in the trial, then they didn’t have a control.  This undermines the usefulness of this study: it has either been subject to post-hoc manipulation or is an uncontrolled trial.

Solà et al (2004) examined, “Non-invasive interventions for improving well-being and quality of life in patients with lung cancer”.  This review contains a reference to a single study of the use of reflexology on ten lung cancer patients (Stephenson, Weinrich and Tavakoli, 2000).  This “showed some beneficial, if short-lasting effects of the interventions”.  However, it was an unblinded, low-quality trial including only ten subjects: such a study cannot provide any reliable evidence.

The Cochrane Library also identifies other relevant reviews. For example, Ernst and Koder (2007) found that, “There are few controlled trials on reflexology. Of those that have been published, all are methodologically flawed and their results are non-uniform. The effectiveness of reflexology is not supported by controlled clinical trials.”

Carpenter and Neal (2005) found that, “existing evidence does not indicate a beneficial effect of magnets or reflexology in the treatment of hot flashes and other menopausal symptoms.”

Wang et al (2008) concluded that, “There is no evidence for any specific effect of reflexology in any conditions, with the exception of urinary symptoms associated with multiple sclerosis.”  The CRD commentary points out that, “There was limited evidence about urinary symptoms in MS based on one small study that assessed multiple outcomes.”

Most recently Ernst (2009) came to the damming conclusion that, “The best evidence available to date does not demonstrate convincingly that reflexology is an effective treatment for any medical condition.”

Just to be fair, I decided to look in PubMed for any additional single studies dealing with pregnancy and fertility issues and turned up a study by Holt et al (2009) on the effect of reflexology on ovulation.  It found that, “… the results suggest that any effect on ovulation would not be clinically relevant.”

The general message found in the literature is that there is no good evidence that reflexology is an effective treatment for anything.

My conclusion: No biological plausibility and no credible supportive evidence.  Given this I would not expect any advertising to make positive assertions about the use of reflexology in any specific conditions.

What the papers say …

The advertising leaflet says a little more about reflexology.  It claims that it can, “offer and opportunity to de-stress and relax” and that it, “may help to relieve problems associated with many day-to-day illnesses”.  It then refers readers to a  “comprehensive” website.

On the website the Fertility page on the website claims that:

“Reflexology may assist with sub-fertility in helping the couple to relax and become less stressed as well as balancing the Endocrine system which is responsible for hormonal levels. (Reflexology also works well alongside IVF treatment.)”

What evidence is presented on the website for these claims?  This is limited to some newspaper articles.  Not very comprehensive.  In 2000 The Independent carried a report entitled, “Hospital tries reflexology to boost fertility”.  This reported on the beginning of a trial by reflexologist Jane Holt, which was apparently due to be completed in 2002.  I cannot find a record of any publication around this time^*, although this investigator appears to be the lead author of a recent study that found, “… any effect [of reflexology] on ovulation would not be clinically relevant.” (Holt et al, 2009).

It seems perverse to cite publicity surrounding the beginning of a trial, rather than the outcome, as evidence.  It’s doubly bizarre as the only PubMed referenced publication by the lead investigator is essentially negative.  The second (undated) article cited (Is reflexology the new cure for infertility?) is a report on the same story.

The final relevant article (Reflexology: can it aid fertility?) reports the experience of Kath and Murray Chapman from Deepcar, Sheffield.  They feel that reflexology helped them to conceive.  This happy anecdote is supplemented by reference to “One trial in Denmark”.  The Daily Mail explains that this, “examined 108 women with an average age of 30 who had been trying to conceive for up to seven years. Many dropped out of the trial, but 19 of the remaining 61 conceived within six months of completing the treatment.”  The details are very sketchy and I’ve not been able to find this study published anywhere.  The report implies that a control group wasn’t used, but in the absence of a proper reference this is not very persuasive to say the least.

The Relaxation Hypothesis

It could be argued that a couple booked in for the “fertility treatment plan” (8-10 visits) might be helped by the relaxation element of the intervention.  It is true that some authors suggest that stress reduction can help couples conceive (Domar, Seibel and Benson, 1990).  Also, according to the UK’s NHS Choices website, “Stress is thought to cause fertility problems …”

However, this must be tempered by the recent Cochrane Review, “Preconception lifestyle advice for people with subfertility” (Anderson, Norman and Middleton, 2010) which concluded that:

“There is no evidence from randomised controlled trials regarding the effects of preconception advice on the chances of a live birth in subfertile people. Infertility is a prevalent problem and has significant consequences for individuals, families and the wider community.

People’s chance of having a healthy, live birth may be impacted upon by factors such as weight, diet, smoking, other substance abuse, environmental pollutants, infections, medical conditions, medications and family medical history.  However, there is no current guideline about what preconception advice should be offered to people presenting for infertility treatment. It is important to determine what preconception advice should be given about these types of factors to people presenting for fertility treatment in order to help them to make positive changes and hopefully improve their chances of conception and having a healthy baby. This review found no evidence from controlled clinical trials about the effect of preconception advice on the chance of a live birth in subfertile people.”

The first thing I noticed is that “stress” isn’t listed as a factor in sub-fertility in this review.  Maybe it’s an omission, or perhaps it’s not as important as might be thought?  I would be happy to hear from anyone who knows this topic well.  For me, the key point is that for sub-fertile people, there doesn’t seem to be reliable evidence from controlled clinical trials to say one way or the other if stress is a factor and, conversely, whether relaxation might help.  This makes any “relaxation hypothesis” for reflexology highly speculative.

However, it’s also worth remembering that there are many cheaper ways to relax than visiting a reflexologist at £28 an hour:  Taking a walk in a park, spending an evening with friends, chilling out to music, or reading a book can all be very relaxing.  They also have the advantage of being free of the exploitative pseudo-medical mumbo-jumbo associated with reflexology.

The Bottom Line

After considering the evidence that I can find, I cannot help but conclude that there is absolutely no justification for claiming that reflexology can be of any help in pregnancy or for sub-fertility.

Given the lack of any biological plausibility or credible positive evidence supporting the use of reflexology for fertility issues, selling it to people struggling to conceive seems both cruel and exploitative.

Singh and Ernst (2008) sum the position up eloquently:

“The notion that reflexology can be used to diagnose health problems has been disproved and there is no convincing evidence that it is effective for any condition.  Reflexology is expensive, and it offers nothing more than could be achieved from a simple, relaxing foot massage”

Some Helpful Information

NHS Choices How can I get pregnant?

NHS Choices How can I improve my chances of becoming a father?

Disclaimer

I try to make sure that what I write is both accurate and fair.  If you think that I have got anything wrong please let me know.  If you are right I will happily change what I have written.

This article does not constitute medical advice.  If you need that please consult a properly registered medical doctor.

In this article, all emphasis in quoted passages is mine.

Notes

*Jane Holt’s website, “Reproductive reflexology” says that, “As the successes began to accumulate I approached Derriford Hospital in Plymouth, Devon and subsequently a Randomised Controlled Research Trial was set up to test the effectiveness in ovulation induction using reflexology on women who suffered Polycystic Ovarian Syndrome …The results are in the process of being analysed which will then be published in a peer reviewed medical journal.”  From this description it would seem that the much heralded study was indeed the one published recently (Holt, et al, 2009) which ruled out clinically significant effects for reflexology on ovulation.  It looks like the website needs updating!

References

Anderson K, Norman RJ, Middleton P. Preconception lifestyle advice for people with subfertility; 2010. Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD008189/frame.html.

Bamigboye AA, Smyth RMD. Interventions for varicose veins and leg oedema in pregnancy; 2007. Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001066/frame.html.

Carpenter JS, Neal JG. Other complementary and alternative medicine modalities: acupuncture, magnets, reflexology, and homeopathy. The American journal of medicine. 2005 December;118 Suppl 12B:109–117. Available from: http://dx.doi.org/10.1016/j.amjmed.2005.09.058.

Domar AD, Seibel MM, Benson H. The mind/body program for infertility: a new behavioral treatment approach for women with infertility. Fertility and sterility. 1990 February;53(2):246–249. Available from: http://view.ncbi.nlm.nih.gov/pubmed/2078200.

Ernst E. Is reflexology an effective intervention?  A systematic review of randomised controlled trials. The Medical journal of Australia. 2009 September;191(5):263–266. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19740047.

Ernst E, Köder K. An overview of reflexology. European Journal of General Practice. 1997 January;3(2):52–57. Available from: http://dx.doi.org/10.3109/13814789709160323.

Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain; 2008. Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001929/frame.html.

Hansen NV, Jørgensen T, Ørtenblad L. Massage and touch for dementia; 2006. Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004989/frame.html.

Harvey R, Hannan SA, Badia L, Scadding G. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database of Systematic Reviews. 2007;CD006394(3). Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006394/frame.html.

Heatley DG, McConnell KE, Kille TL, Leverson GE. Nasal irrigation for the alleviation of sinonasal symptoms. Otolaryngology–head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2001 July;125(1):44–48. Available from: http://dx.doi.org/10.1067/mhn.2001.115909.

Holt J, Lord J, Acharya U, White A, O’Neill N, Shaw S, et al. The effectiveness of foot reflexology in inducing ovulation: a sham-controlled randomized trial. Fertility and sterility. 2009 June;91(6):2514–2519. Available from: http://dx.doi.org/10.1016/j.fertnstert.2008.04.016.

Mollart L. Single-blind trial addressing the differential effects of two reflexology techniques versus rest, on ankle and foot oedema in late pregnancy. Complementary therapies in nursing & midwifery. 2003 November;9(4):203–208. Available from: http://dx.doi.org/10.1016/S1353-6117(03)00054-4.

Poole H, Glenn S, Murphy P. A randomised controlled study of reflexology for the management of chronic low back pain. European journal of pain (London, England). 2007 November;11(8):878–887. Available from: http://dx.doi.org/10.1016/j.ejpain.2007.01.006.

Singh S, Ernst E. Trick or treatment?  : Alternative medicine on trial. Bantam Press; 2008. Available from: http://www.worldcat.org/isbn/0593061292.

Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour; 2006. Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003521/frame.html.

Solà I, Thompson EM, Subirana CM, Lopez C, Pascual A. Non-invasive interventions for improving well-being and quality of life in patients with lung cancer. Cochrane Database of Systematic Reviews. 2004;CD004282(4). Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004282/frame.html.

Stephenson NL, Weinrich SP, Tavakoli AS. The effects of foot reflexology on anxiety and pain in patients with breast and lung cancer. Oncology nursing forum. 2000;27(1):67–72. Available from: http://view.ncbi.nlm.nih.gov/pubmed/10660924.

Wang MY, Tsai PS, Lee PH, Chang WY, Yang CM. The efficacy of reflexology: systematic review. Journal of Advanced Nursing. 2008 June;62(5):512–520. Available from: http://dx.doi.org/10.1111/j.1365-2648.2008.04606.x.

White AR, Williamson J, Hart A, Ernst E. A blinded investigation into the accuracy of reflexology charts. Complementary therapies in medicine. 2000 September;8(3):166–172. Available from: http://dx.doi.org/10.1054/ctim.2000.0380.

Williamson J, White A, Hart A, Ernst E. Randomised controlled trial of reflexology for menopausal symptoms. BJOG: An International Journal of Obstetrics and Gynaecology. 2002 September;109(9):1050–1055. Available from: http://dx.doi.org/10.1111/j.1471-0528.2002.01504.x.

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