LITERATURE REVIEW of Postoperative Pain and Foot Reflexology

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Post operative pain: The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (Black, J M, 2005). Post operative pain can be defined as pain resulted from surgical intervention. Pain is generally protective, it warns of tissue damage and prompt treatment, but post operatively it can hold up recovery. Factors that affect post operative pain consist of the previous experience, surgical intervention, intra operative pain management, site and size of incision and extent of surgical trauma (Rahman M, Beattie J, 2005).

The basic pain mechanism consists of mainly four processes such as transduction, transmission, perception and modulation (Koeppen B M, Stanton B A 1996). Surgical tissue damage causes release of substances such as bradykinin, arachidonic acid, histamine, 5-hydroxytriptamine, substance P and prostaglandins. These chemicals stimulate peripheral pain receptors which transmit the pain impulses. This pain impulse is transmitted to spinal cord through neuronal fibers. From there sensory information is carried through the spinothalamic tract and spinonueclear tract to the thalamus and the reticular activating system. Neurons from the thalamus project to cerebral cortex for the conscious perception of pain. (Krik.R.M, W.T. Ribbans, 2004).When pain stimulus reaches the brain stem and thalamus naturally it stimulate the release of endorphins and enkephalins,which may inhibit pain transmission at spinal cord(Rahman M, Beattie J, 2005).

Foot reflexology: Reflexology is a bodywork modality in the field of Complementary and Alternative Medicine (CAM). Reflexology is the act of applying pressure on specific areas of hands and feet that correspond to particular organs and glands of the body using specific thumb, finger and hand techniques. Reflexology therapies are classified in to three types: ear reflexology, hand reflexology and foot reflexology. The basic concept of foot reflexology promotes homeostasis. Foot reflexology improves blood circulation, lymphatic circulation and also motivates relaxation; good sleep and wound healing (Julia Layton, 2002).

History of foot reflexology: The treatment of feet was well known in China, Korea and other eastern countries. It was believed to be originated 5000 years back. This is supported by an Egyptian Tomb Drawing. This drawing shows four people, one person being treated with foot reflexology and another with hand reflexology.

William Fitzgerald, an American ENT specialist reintroduced foot reflexology to the modern era. She did several works on reflexology. Later on Eunice Ingham, a physical therapist popularized this therapy through her books "the stories the feet can tell "and stories the feet have told (Marquardth, Hanne, 1999).

Theories of foot reflexology: The core theories of foot reflexology derived from zone theory and meridian theory. The effects of foot reflexology are also explained by energy theory, lactic acid theory, theory of proprioceptive nervous receptors and psychological theory. Melzack and Wall's, gate control theory and endogenous theory also explains about the effects of reflexology in reducing pain (Stephenson N L, Weinrich S P and Tavakoli A S, 2000).

Zone theory: Fitzgerald, according to the effects of treatment he observed, divided the body in to 10 zones. The longitudinal body zones appear as equally large vertical fields leading from medial to lateral zones. The organs, tissue and systems through which a longitudinal zone passes in the body are represented in the same zone on the feet on reduced scale. Application of pressure on any reflex point in hand or feet would have a corresponding effect on different organs lying within that zones .These longitudinal zones are considered as energy path ways , thus pressure applied on feet have a corresponding effect on organs and systems of that path way. The concept of this theory assumed human beings were alive with a life force and this life force flow through energy pathways (Marquardth, Hanne, 1999).

Meridian theory: This theory was modified from zone theory by Ingham. Ingham mapped the foot areas showing the relationship between energy pathways and reflex points corresponding to visceral organs from her experience. For example the pressure applied to the part of left foot has effect on corresponding visceral organs and glands on the left side (Marquardth, Hanne, 1999).

Energy theory: Energy theory proposes that body parts communicate through an electromagnetic field and sometimes the energy pathway become blocked. Foot reflexology promoted good circulation of energy without any block and thus augment the state of body balance and organ function (Mary Cade, 2002).

Lactic acid theory: Any stress releases the lactic acid and this deposit in an energy pathway as microcrystal's and obstructs the free flow of energy. Foot reflexology mashes the crystals and allows for the free flow of energy (Mary Cade, 2002).

The gate control theory: Melzack and Wall explained mechanism of pain and gate control theory of pain. The gate control theory explained that the transmission cells (T calls) are controlled by a spinal gating mechanism situated in the dorsal horn. This spinal gating mechanism influenced by the activity of large and small diameter nerve fibers. Stimulation of large fibers activates the inhibition of neuronal transmission and stimulation of small fibers results in transmission of pain impulses. Foot reflexology helps in inhibition neuronal transmission by stimulating large fibers (Nancy,L.N et al. 2007).

Innoculous stimuli, such as rubbing a hurt area, can block or reduce pain sensation. Such stimulation activates the large diameter fibers and their activity leads to release of GABA and other neurotransmitters. GABA acts by both pre synaptic and post synaptic mechanism to shut down the activity of spinothalamic tract cells (Koeppen B.M, Stanton B. A, 1996).

Foot reflexology also reduces stress and fear by providing a warm feeling, security and trust and this helps in transporting direct impulses to brain and inhibit pain impulses by closing the gates at spinal cord.

Endogenous pain control theory: Foot reflexology helps in transmission of neuronal impulse to stimulate pituitary gland of hypothalamus to release endorphins (Xavier Regina, 2007). Endorphins are endogenous opiate neuropeptide produced by the body and activate the opiate receptors and consequently have a significant analgesic action. The action of endogenous opiate neuropeptide was believed to work at CNS by inhibiting release of substance P and stopping the nociceptors by paring with suitable opiate receptors (Hawthorn Jan, Kathy Redmond, 1998).

Foot reflexology in pain reduction: A study was at Division of Science and Design, University of Canberra, Australia on the use of foot massage as a nursing intervention in patients admitted with cancer. 87 patients were participated in the study and each one received a 5-minute reflexology foot massage per foot. The study reported that the reflexology has a significant and immediate effect on the pain, nausea, and relaxation, when it was measured with a visual analog scale. (Grealish L, 2000).

Nationwide research study undertaken in Denmark reported that, reflexology treatment has a positive effect on patients suffering from migraine and tension headaches. The study was done at the Department of Social Pharmacy, The Royal Danish School of Pharmacy with the help of five reflexology associations. 220 patients were participated in the study. Reflexology was performed by 78 fully trained reflexologist. Among the patients who took part in the study, ninety percent reported that they had already started to take the prescribed medication one month before the study and, out of them, 36 percent had experienced ill effects from the medicines. Eighty one percent of the prescribed medicine in the acetylsalicylic acid and paracetamol group was taken at least twice a week and 72% of the stronger medicines were taken at least once a fortnight which point out that the greater part of the patients were suffering from moderate to severe symptoms. After three months of reflexology treatments, eighty one percent of patients confirmed that reflexology helped them in reducing their symptoms. Nineteen percent of the patients re-ported that they had been able to completely stop the medications they had been taking before the study (Carlson Selvia, 2006).

A study was conducted at the Hospital of Beijing College of Languages to assess the effect of reflexology treatment on acute lower back pain. Twenty patients between the ages of 35 and 55, suffering from lower back strain was participated in the study. Ten reflexology therapies were delivered to each patient. All patients reported that the treatment had effectively reduced their pain. 5 of them obtained complete relief after one treatment, 10 patients obtained relief after 3 to 4 treatments and 5 patients got complete relief only after 5 to 7 treatments. No analgesics or other medications were used all over the course of treatments (Xiao Zhenge, 2002).

A study was conducted to assess the effectiveness of foot reflexology on pain and anxiety in patients admitted with breast and lung cancer. It was a quasi-experimental, cross over study done at medical and oncology units of a 314-bed hospital in the South-Eastern United States. Twenty-three in-patients with breast or lung cancer were taken for the study. The bulk of the samples were receiving regularly scheduled opioids and adjuvant medications. Procedures included a foot reflexology to both feet for 30 minutes during intervention condition and with at least a two-day break during control condition for each patient. No changes were made in patient's usual schedule or medications. Following the foot reflexology intervention, patients with breast and lung cancer experienced a significant reduction in anxiety and pain (Stephenson N L, Weinrich S P, Tavakoli A S, 2000).

A study was conducted to assess the effectiveness of foot reflexology as a pain killer in China (1998). Reflexology was done to 60 individuals between ages 1 to 73 to reduce the pain resulted from toothache, headache, sore throat, stiff neck, shoulder pain,old wound, breast pain, chest & rib pain, dysmenorrhoea, abdominal pain , wrist and leg pain and joint pain in limbs. Reflexology sessions lasted for 20 minutes to 40 minutes. Following one session 18 of the 60 were healed. 11 were nurse back to health following 2 or 3 sessions, 22 were effectively treated after 2 or 3 sessions. Reflexology was not effective for 9 cases after 1 to 3 sessions (Jin Hui, 1998).

Foot reflexology in post operative pain reduction: A study was conducted at AIIMS, New Delhi (2002-2004) to find out the efficiency of reflexology in postoperative pain management. Sixty patients were divided randomly into Reflexology group (foot reflexology and required quantity of standard drugs) and Control group (standard quantity of standard drugs alone).Standard drugs included are NSAID (Diclofenac) and Opioids (Pethidine and Fentanyl).Pain score was measured by using a visual analog scale of 0 - 10. Pain was measured at the time scale of 0, 2, 6, 24 hours. 0 hours is the time which patient was shifted to recovery room. The results showed a considerable decrease in pain scores and decrease in the requirement and quantity of drugs among reflexology group compared to control group (Shewtha Choudary et al., 2006).

A study was carried out to examine the effect of foot reflexology on sternotomy pain of patients undergone CABG at Iran University of Medical Sciences (2007). This was a quasi-experimental study, 90 patients were randomly divided into three groups of case, control and placebo. The reflexology group received a 10-minute right foot massage in desired location, two times a day with 6 hours interval for 2 successive days. The placebo group received a 10-minute left foot massage and the control group received no intervention. Pain was assessed using visual analogue scale. Outcome showed that the mean of pain intensity before and after intervention in three groups had a significant difference. In the case group average pain intensity before the intervention was 6.4(±2.1) and after the intervention was 3.4(±5.1). In control group the mean of pain intensity before and after intervention was respectively 5.1(±1.7) and 5(±1.9). Independent t-test showed a significant reduction in intensity of postoperative pain between case and control groups (Bozorgzad, 2007).

A study was conducted to look into the efficacy of foot reflex therapy as adjuvant treatment modality in reducing pain and anxiety in postsurgical patients with gastric and hepatocellular cancer at Taiwan (2005). It was a randomized controlled trial. Sixty-one patients who had undergone surgery for gastric or hepatocellular carcinoma were randomly assigned to intervention (n = 30) or control (n = 31) group. Patients in the experimental group received 20 minutes of foot reflexotherapy in addition to the usual pain management during 2nd, 3rd and 4th postoperative days. Patients in the control group got usual pain management only. Outcome was measured using short-form McGill Pain Questionnaire, VAS, summary of the pain medications taken, and the Hospital Anxiety and Depression Scale. Intervention group reported less pain and anxiety over time when compared with the control group. The study also revealed that the patients in the experimental group received significantly less pain medications than the control group.(Tsay, Shiow-Luan et al., 2008).

A study was conducted to compare effects of symptom management with reflexology on pain and frequency of pain medication taken in old age patient with prostatectomy at Suratthanee Hospital, Thailand (2005). Quasi-experimental, pretest -post test design was used with a control groups. 40 elderly patients were selected and allocated to experimental and control groups. The instrument used for the study consisted of four sessions; Symptom experienced assessment, Knowledge providing, Reflexology and evaluation phases. Data were analyzed by using descriptive statistics and t-test. The study reported that the posttest mean score on pain of an experimental group was significantly lower than of the pretest. The posttest mean score of pain of an experimental group was significantly lower than of a control group. The posttest mean score of frequency pain medication taking of an experimental group was significantly lower than of a control group (Tanyakhanok Pongpiyapibon, 2005).

A study was conducted to find out the effectiveness of foot reflexology on pain level, vital signs and satisfaction in patients with abdominal surgery by a post graduate student of Mahidol University, Taiwan (2003). It was a quasi experimental research with simple cross over design. Thirty patients were randomly selected to control group and experimental group. Control group received 30 minutes of supportive education and experimental group received 30 minutes of foot reflexology. Pain assessment and vital signs were recorded pre, immediately after therapy and at 15 minutes and 45 minutes interval. The results showed that patient received foot reflexology had marked reduction in pain compared to those received supportive education. It also reported a marked effect in vital signs (Sarunya, 2003).