Information for Health Professionals
We understand that time is in short supply to health professionals, so we have gathered together the most pertinent information here.
What is Reflexology?
Reflexology is a non-intrusive complementary health therapy, based on the theory that different points on the feet, lower leg, hands, face or ears correspond with different areas of the body. These areas have been mapped over time and are used by reflexologists worldwide. There are a number of research studies that shed some light on how reflexology might work but they are not conclusive. However, there are two studies from Japan using functional magnetic resonance imaging that show increased blood flow into areas of the brain corresponding to the reflexology point of action. This supports the fundamental premise of reflexology that by working specific reflex area on the feet has an effect on blood flow in the corresponding area of the body. 
Reflexologists work holistically with their clients and however reflexology is viewed, there can be no doubt that what it does provide is a period of time (usually an hour) where the client has one to one attention, relaxation and supportive touch in an empathic and non-judgemental listening environment. Reflexology is unusual even as a complementary therapy because unlike others the person receiving the treatment is positioned a comfortable body-length away from the therapist yet face to face. This positioning is conducive for clients to talk if they want while therapeutic touch is provided. Within the NHS reflexology is used in 62% of cancer units  as a supportive therapy with very few safety concerns as no adverse events have been highlighted in any of the studies, while high rates of satisfaction are noted.
Nakamaru T, Miura N, Fukushima A, Kawashima R. Neurosci Lett. 2008 Dec 19;448(1):6-9. doi: 10.1016/j.neulet.2008.10.022.
 Activity in the primary somatosensory cortex induced by reflexological stimulation is unaffected by pseudo-information: a functional magnetic resonance imaging study. Miura N, Akitsuki Y, Sekiguchi A, Kawashima Complement Altern Med, 2013 May 27;13:114.
 Availability of complementary and alternative medicine for people with cancer in the British National Health Service: results of a national survey. Egan B, Gage H, Hood J, Poole K, McDowell C, Maguire G, Storey L. Complement Ther Clin Pract, 2012 May;18(2):75-80.
What happens when someone has a reflexology treatment?
A full medical history will be requested at the first treatment, and it will be necessary to sign a consent form for treatment. This information will be kept confidential and is subject to GDPR which the practitioner will provide information on. Reflexology is a very easy therapy to receive; depending on the type of reflexology, the most clothing that will have to be removed for a treatment to take place will be your socks and shoes.
The therapist will then use their hands to apply pressure to the feet, lower leg, hands, ears or face, depending on the type of reflexology chosen. The client may feel areas of transient discomfort during the treatment, but generally the experience should be relaxing. Treatment length varies and will be discussed at the initial consultation. Most treatments last 40-50 minutes.
Some therapists work from clinics and treatment room and some can offer home visits. This is particularly useful for clients where mobility is limited.
The therapist may recommend a course of treatments.
How can reflexology help you and your patients?
Reflexology is an extremely popular complementary therapy which is relevant for all stages of life. There are a few situations, where in the best interest of the patient, reflexology would not be suitable. AoR reflexologists are aware of these and they are listed in our Contraindications List.
Reflexology promotes deep relaxation, and this can be very beneficial in reducing stress levels. This resulting reduction in stress levels can bring an improved sense of wellbeing in clients.
Reducing the high stress levels often associated with long term conditions can potentially bring many benefits to both patients and their carers. Relaxation, affective touch and the therapeutic relationship can also help build resilience and allow patients to gain the mental strength needed to take on lifestyle changes needed to promote better health. Many charities and professional organisations working in the mental health sector also use reflexology as a supportive therapy. For example you can find reflexology listed on the Royal Society of Psychiatrists website and also on Mind’s website too.
Many people use reflexology as a way to help them manage their own wellbeing and health. In the NHS Long term plan section 1.38 the NHS states it wants to ‘ramp up support for people to manage their own health’.
The Association of Reflexologists would like to support the NHS and GP’s in achieving this ambition by finding ways to work closer together.
The AoR welcomes the recognition amongst health professionals that physical, emotional and mental health are intrinsically linked, and that only by treating a patient as a whole person can we tackle the root cause of illness and deal with the problem of patients presenting with multiple and complex conditions. We believe that by working closely with primary and secondary care providers that we can help build the body of evidence that shows that complementary therapies like reflexology can be an effective tool in strategies for improving quality of life and outcomes for patients.
Ensuring patient safety
Ensuring patient safety is of paramount importance. Members of the Association of Reflexologists hold a nationally recognised qualification (covering National Occupational Standards and the Core Curriculum), are fully insured, follow a comprehensive Code of Practice and Ethics which they must abide by, we have a complaints procedure for the public, we require all members to continue their learning and professional development throughout their career and specify a minimum annual numbers of hours. MAR (& FAR) status means the practitioner has to have passed a rigorous quality control process before they can even enter membership, and they are required to continue their learning about reflexology throughout their career.
Reflexology has had voluntary regulation in place since 2009, set up to ensure patient safety. All registrants have agreed to be bound by the highest standards of conduct. The register is accredited by the Professional Standards Authority for Health and Social Care (PSA).
Many of our members are also registered with the CNHC. CNHC is the UK voluntary regulator for complementary healthcare practitioners that was set up with government support to protect the public by providing a UK voluntary register of complementary therapists. CNHC has agreed that the Association of Reflexologists may verify applications from our Honorary, Fellow and Full members for CNHC registration and we encourage members to register in order to gain the CNHC quality mark.
Reflexology and its use in healthcare
Reflexology allows the person being treated to be a comfortable body length away from the therapist yet face to face. This positioning is very conducive for clients to talk of they want to while therapeutic touch is provided. Many UK cancer centers, out-patient units, and hospices are providing complementary services. There is strong anecdotal evidence that complementary therapies assist in the palliation of physical and psychological symptoms. Within the NHS reflexology is used in 62% of cancer units as a supportive therapy with very few safety concerns as no adverse events have been highlighted in any of the studies, while high rates of satisfaction are noted.
Where’s the evidence?
Evidence Based Medicine (EBM)
Whenever reflexology is mentioned within a clinical setting the question that always arises is where’s the evidence? If only large randomised trials are used to make evidence based decisions then it is absolutely accepted that reflexology does not have that level of evidence. But the original Sackett definition of evidence based medicine (EBM) is:
‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.’ 
This definition actually does not define EBM as only requiring large Randomised Controlled Trials but more that the best research available together with a clinical decision should be brought into the decision making process for individual patient care. The clinical expertise originates with the health professionals involved but the patient also brings with them personal preferences and expectations that are involved in the decision-making process. It further goes on to say, that the evidence by itself, does not make the decision, but it can help support the patient care process. The full integration of these three components into clinical decisions enhances the opportunity for optimal clinical outcomes and quality of life. EBM actually melds very well with the NHS England ‘Putting patients first’ policy, that not only should the best decision be made for that individual patient but that they themselves should be involved in the making of that decision. With this in mind, while the best evidence for using reflexology is not a large and comprehensive collection of research studies, neither is reflexology solely specific to one medical condition. The very nature of reflexology as a complementary therapy means it is not condition limited, it can be used across many areas where patients are feeling stressed, anxious or in pain and/ or need a boost to their quality of life and wellbeing. This lack of specificity does not bode well for research meta-analyses, and when meta-analysis for complementary therapies is undertaken it usually results in a negative outcome. This does not necessarily mean that reflexology has no worth but rather that its action is too heterogeneous to be successfully analysed using this system.
If, however, the existing best evidence; that of the separate research studies are taken into account, then it can be seen that there is potential in this low cost, supportive therapy. Potential that could help care for patients in a way that perhaps is missing from the present-day NHS.
 Meta-analysis: Its strengths and limitations Esteban Walker, Adrian V. Hernandez, Micheal W. Kattan Cleveland Clinic Journal of Medicine. 2008 June;75(6):431-439
Long term conditions
Conditions, especially long term ones, can be a complex vortex of illness, pain, anxiety, depression, emotions and needs. Standard medical care does not cope well with complexity as it rather follows straight paths as compared to swirling spirals. There is evidence that people with long term conditions receive poorer quality of care than those with a single condition.
In the field of cancer care, in 2009 62% of cancer units in the UK provided reflexology and it was second only to counselling. This vulnerable and very unwell group have nothing but good things to say about reflexology, with the only complaint being lack of availability of appointments:
‘The improvement in my lower back pain has been staggering’
‘My sleep has improved and I feel relaxed and content’
‘I found having treatments helped me focus and be more positive and able to deal with incidents that made me feel fragile.’
When reflexology for cancer care was evaluated in a busy London hospital there was a 28% change in perceived well-being. 
‘Patients appear to perceive complementary therapies as enhancing compassionate care and providing comfort during an extremely difficult clinical experience.’
Even in a palliative care setting all participants felt their quality of life had improved and words such as relaxed and comforted were used while symptoms were reduced. 
When considering mental health, a study of reflexology on the psychological effect of having breast cancer resulted in a statistical improvement in quality of life even at one month after the completion of the intervention. This difference was to a level that was calculated as being clinically worthwhile. While a small cross over trial (the patients were their own control) from America in lung and breast cancer patients showed that both groups of patients had a significant decrease in anxiety after reflexology.
 Availability of complementary and alternative medicine for people with cancer in the British National Health Service: results of a national survey. Egan B1, Gage H, Hood J, Poole K, McDowell C, Maguire G, Storey L. Complement Ther Clin Pract. 2012 May;18(2):75-80
 Is reflexology as effective as aromatherapy massage for symptom relief in an adult outpatient oncology population? Dyer J, Thomas K, Sandsund C, Shaw C. Complement Ther Clin Pract. 2013 Aug;19(3):139-46
 Effects of complementary therapies in cancer care. Briscoe J, Browne N (2013) Nursing Times; 109: 41, 18-20.
A randomised, controlled trial of the psychological effects of reflexology in early breast cancer. Sharp DM1, Walker MB, Chaturvedi A, Upadhyay S, Hamid A, Walker AA, Bateman JS, Braid F, Ellwood K, Hebblewhite C, Hope T, Lines M, Walker LG. Eur J Cancer. 2010 Jan;46(2):312-22.
 The Effects of Foot Reflexology on Anxiety and Pain in Patients With Breast and Lung Cancer ONCOLOGY NURSING FORUM Stephenson, N. L. Weinrich, S. P. Tavakolil, A. S. 2000 VOL 27; PART 1 , page(s) 67-76
When reviewing the pain in cancer arena, there have been several studies that suggest that there is a place for reflexology in the care pathway. A study by Stephenson in the USA in the difficult to treat group of metastatic cancer showed an ‘immediate positive effect of reflexology for patients with metastatic cancer who report pain’. A second study from America on post-operative pain and anxiety amongst patients with digestive cancer showed that together with standard postoperative analgesia, compared to a control of usual pain management, the reflexology group showed statistically less pain, anxiety and requirement for analgesia than the control group.
When we look at pain outside of the cancer field, a recent exploratory study of reflexology with pain threshold and tolerance compared a sham TENS machine treatment as the control to reflexology in an ice bath pain experiment. The results showed that the reflexology treatments significantly increased pain tolerance at 60 minutes, 90 minutes, and 120 minutes. There was a reduction in heart rate over the first 60 minutes too, indicating that the results may be due to an anti-nociceptive effect. ‘These results suggest the possibility that reflexology may be useful on its own or as an adjunct to medication in the treatment of pain conditions in man’.
One of the issues regarding pain is that it can result in the long term use of medication, of both over the counter painkillers (OTC) and prescription only medication (POM). Non-steroidal anti-inflammatories have potential to cause stomach ulcers, kidney disorders and even liver failure and act additively when used concomitantly with other common drugs. Even multiple doses of Paracetamol and/ or the prophylactic medicines can produce drug induced refractory headaches
In a small study of students with dysmenorrhea a comparison was made to Ibuprofen. The Ibuprofen was prescribed 400mg every 8 hours over 3 days for three cycles. The reflexology group received 10 treatments over the first 2 cycles, but no treatment during the third cycle. Reflexology was associated with a greater reduction of menstrual pain duration and intensity across all three cycles as compared to the Ibuprofen treated group.
Published studies of reflexology indicate that it aids with Migraines. Lafuenta et al compared reflexology to Flunarizine, a drug often used in the treatment of headache. 32 patients with a variety of headaches including Migraines were randomised into two groups, one received reflexology and a placebo tablet, while the other received Flunarizine and an unspecific friction massage of the arms to control for human contact. The frequency and pain intensity was measured and the results show that the reflexology was at least as effective as the Flunarizine which could be particularly useful where pharmacological intervention is contraindicated.
In a study comparing reflexology to segmental massage in females with Migraine Wojciech et al looked at the frequency, intensity and duration of Migraine attacks. All variables were reduced at the end of the intervention with both therapies. At three months post intervention, the variables were both still improved with both therapies, however, if the Friedman test is applied the results were much more favourable to the reflexology group. Finally, a study was carried out on Migraines induced by nitroglycerin which is used in the treatment of acute and chronic angina and congestive heart failure. Reflexology was applied to the big toes, which under reflexology theory is representative of the head; compared to application of pressure to another irrelevant part of the heel or no treatment at all as a control. This study was on all males which is unusual for Migraine research but which is reflected the original presenting condition of angina and congestive heart failure. The results showed a highly statistical difference for the reflexology group (p=0.000) using the numeric rating scale for pain as compared to the other two groups.
Effects of Reflexotherapy on Acute Postoperative Pain and Anxiety Among Patients With Digestive Cancer Shiow-Luan Tsay, Hsiao-Ling Chen, Su-Chiu Chen, Hung-Ru Lin, Kuan-Chia Lin Cancer Nursing Vol. 31, No. 2, 2008
 Exploratory study on the efficacy of reflexology for pain threshold and tolerance using an ice-pain experiment and sham TENS control Carol A. Samuel Ivor S. Ebenezer, Complementary Therapies in Clinical Practice Volume 19, Issue 2 , Pages 57-62, May 2013
 Analgesic, antiulcer, antithrombotic drugs and organ damage: a population-based case-control study. Battelli D1, Riccardi R, Piscaglia AC, Stefanelli ML, Mussoni L, Zani A, Vitale V, Monachese N. Minerva Med. 2015 Dec;106(6):323-31.
 Comparing the effects of reflexology methods and Ibuprofen administration on dysmenorrhea in female students of Isfahan University of Medical Sciences. Valiani M, Babaei E, Heshmat R, Zare Z.Iran J Nurs Midwifery Res. 2010 Dec;15(Suppl 1):371-8.
 Reflexology treatment in comparison to prophylactic flunarizine treatment (powerful migraine medication) on patients suffering from cephalalgia (permanent) headache. Lafuente A., Noguera M., Puy C., Molins A., Titus F. and Sanz F. Dr. Annemarie Kesselring, SBK, Institut fur Pflegeforschung, Bern.
 Effects of feet reflexology versus segmental massage in reducing pain and its intensity, frequency and duration of the attacks in females with migraine: a pilot study. Wojciech K, Pawel L, Halina RZ.J Tradit Chin Med. 2017 Apr;37(2):214-9.
 Effect of applying reflexology massage on nitroglycerin-induced migraine-type headache: A placebo-controlled clinical trial. Imani N, Shams SA, Radfar M, Ghavami H1, Khalkhali HR.Agri. 2018 Jul;30(3):116-122.
Other long term conditions
When it comes to the support and management of patients with other long term conditions there have been studies on reflexology in Multiple Sclerosis (MS), Parkinson’s disease (PD) and Dementia. The studies in MS show reflexology resulted in an improvement of various symptoms of MS to a statistically significant level. No improvement was seen in the control group. Extraordinarily, the statistical improvement in spasticity (which is the continual contraction of muscles causing stiffness) and the statistically borderline improvement in muscle strength together are remarkable, as the standard drug intervention for spasticity normally results in muscle weakness with its inherent problems. The treatment was safe with no adverse effects noted. Several other studies have agreed the beneficial effect of reflexology in this group of patients.
In Parkinson’s disease, the results suggest that during the therapy stage the specific outcome measure indicated improvement across all dimensions with the exception of communication which stayed the same. This could suggest that although benefits were not sustained with cessation of treatment, extended (and perhaps more frequent) treatments might continue to benefit and improve the well-being of people with Parkinson’s disease
Dementia is a costly long term condition which requires specialist care. When mild to moderate dementia patients received reflexology, as compared to a massage control, the residents demonstrated significant reduction in observed pain and salivary alpha-amylase. This study provides preliminary support for the efficacy of reflexology as a treatment of stress in nursing home residents. There has even been a study of reflexology on anxiety and sedation needs of patients in the ICU and reflexology was shown to greatly reduce the physiological signs of anxiety even under medical sedation, which suggests its effect is more than placebo. 
 Reflexology treatment relieves symptoms of multiple sclerosis: a randomised controlled study MULTIPLE SCLEROSIS Siev-Ner I, Gamus D, Lerner Geva L, Achiron A.2003 VOL 9 PART 4 pages 356-361
 Can reflexology maintain or improve the well-being of people with Parkinson’s Disease? Johns C, Blake D, and Sinclair A Complementary Therapies in Clinical Practice.2010 VOL 16; NUMBER 2, page(s) 96-100
 The clinical efficacy of reflexology in nursing home residents with dementia. Hodgson NA, Andersen S. Center for Applied Research on Aging and Health, Thomas Jefferson University Philadelphia, PA 19107, USA. firstname.lastname@example.org
There is also the issue of effectiveness gaps in current healthcare this is defined as areas for which the care that is provided is less than acceptable to patients. A classic example of this is lymphoedema post breast cancer surgery, where current treatments have accepted low results, poor adherence and poor patient satisfaction. Whereas a study of 26 women undergoing a specific reflexology technique, all showed significant change in volume in the effected arm that was maintained for more than six months with high patient satisfaction. 
Based on these, and many other studies in the UK and elsewhere, we would propose that there is a place for reflexology within the modern health care system.
Patients diagnosed with chronic or long term conditions may require constant medication but not necessarily high levels of medical professional contact, it is estimated that even the most disadvantaged LTC patient can only see their medical care givers 1% of the time, leaving them to cope 99% of the time on their own. Some personalised care and support could be more helpful in the long term. Especially in the vulnerable and potentially isolated groups such as the elderly or those unable to work. It is known that being lonely can be as damaging to health as smoking 15 cigarettes per day.  The Blackdown Healthy Living and Activity Centre in Devon is successfully providing complementary therapies including reflexology as part of its support for the elderly.
Other countries such as America and Australia and Korea are investing in research into complementary therapies; they have their own medical Institutes such as NCCIH looking at ways to improve care of hard to manage symptoms such as pain, anxiety and depression using complementary therapies. What we need in this country is a level of bravery and innovation to try some out of the box thinking. Perhaps the application of repeated pharmaceutical interventions which can lead to all the downstream effects of polypharmacy such as gastrointestinal ulcers, liver problems and even addiction, is not the only route. Making people with chronic and long term conditions feel better, more empowered and capable of achieving wellbeing is a goal of any health service. Within the five year forward review it is clear that innovation and new ways of working are acceptable and indeed necessary given the current funding constraints, that observational studies are becoming more viable and that commissioning through evaluation is possible.
As reflexologists we do not treat conditions, long term or otherwise, we support people, treating them holistically.
 Use of reflexology in managing secondary lymphoedema for patients affected by treatments for breast cancer: A feasibility study Judith Whatley , Rachael Street , Sally Kay , Philip E. Harris Complementary Therapies in Clinical Practice 23 (2016)
 Social relationships and mortality risk: A meta-analytic review. Holt-Lunstad, J., Smith, T. B., & Layton, J. B. (2010). PLoS Medicine, 7(7)
What can we do for you?
What to look for in a practitioner
When talking to a patient about the possibility of using reflexology to support their wellbeing and health we want you to feel confident that as many risks are mitigated as possible.
That’s why the AoR guarantees that all AoR members have guaranteed level of training, insurance and expert practice skills maintained by mandatory continuing professional development.
If you would like to call us to discuss your requirements please call Helen Turier on 01823 351010, extension 127.
Cost benefit analysis
The AoR is working with integrative healthcare practices to help prove the cost benefit to the NHS of the use of complementary therapies such as reflexology for patients. Please do contact us if you wish to be included.
Social prescribing is designed to support people with a wide range of social, emotional or practical needs, and many schemes are focussed on improving mental health and physical well-being. The AoR can support local social prescribing initiatives that are wish to use reflexology to support their communities wellbeing needs. All our members follow a code of professional conduct, are fully insured and must maintain their CPD to remain on our register.
AoR Pilot Project
More information coming soon.
We're here to help!
If you need any further information regarding reflexology, becoming a student or joining the AoR, then feel free to call us on 01823 351010 or