In the last post on acupuncture, I noted that the University of Maryland offered reflexology along with other supplements, and complementary and alternative medicine (SCAMs). I was uncertain as to the particulars of this SCAM, and this post is a result of those investigations.

Although messy in reality, science is a tool that gives us an idea as to how the real world functions. People will observe some aspect of nature, often for a lifetime, and from those observations discover a pattern in the data. Tycho Brahe spent a life carefully measuring the orbits of the planets; the data was used later by Kepler to determine that the planets orbit in an ellipse with the sun at one of the foci. If you have knowledge of the history of science, you realize what an amazing feat this represents, both in the measurement of the orbits and the analysis of the data. Careful observation, analysis of the data, then conclusions.

This is in contrast to SCAMs, where so many of the interventions are discovered by revelation, and then developed independently of data and observation. Palmer and chiropractic, von Peczely and iridology, Usui and reiki are examples. These geniuses discovered aspects of existence unseen by anyone before or after.

In that time honored pantheon is Dr. William Fitzgerald who, at the turn of the last century, “discovered” that the human body is divided into 10 longitudinal energy zones that end in the hands and the feet. By massaging these zones, you could heal disease and alter bodily functions. These are reminiscent of the meridians of acupuncture, and will soon be illustrated in the New England Journal of Medicine (see posts Aug 4 and 13). Fitzgerald named it Zone Therapy, and it went by that name until the 1960’s, when Eunice Ingham decided that, since all the energy zones ended in the feet, that it was the terminus of the energy zones that was the important aspect of Zone Therapy.

The body, it turns out, is far more crowded that we could ever have expected from our understanding of gross anatomy and histology. There is so much packed into our bag of meat, I am surprised that we do not explode, although perhaps we do have a potential explanation for spontaneous human combustion: the friction of all the projections and energy channels described by various SCAM’s rubbing together in a tight space.

There is the map projected on the iris with iridology, the maps on the ear, the tongue, the head, the hand, and the feet of the various acupuncture styles. There are the meridians of acupuncture and zone therapy, the energy flows of reiki and chiropractic. And there is the map of the body projected onto the feet and hands by reflexologists. The feet must be particularly crowded as the maps for foot acupuncture are different than the maps for reflexology; no wonder my feet ache at the end of the day.

Reflexologists are of the opinion that by manipulating the feet, hands and/or ears that correspond to body parts they can induce changes in those body parts. Touch the liver zone on the foot, alter the liver in the abdomen. Alexander Pushkin could vouch for the veracity of a subset of those interventions. Others are of the opinion that the manipulation of the feet, hands and/or ears alters the qi balance in the patient. However, as the Reflexology Association of American notes, “no one definition that will work in all situations and yet, because of the multi dimensional affect [sic] of Reflexology, all are true at [sic] defining the work we do. ”

And it is true, these definitions are limiting, as they do not encompass … well, let’s be nice and call them the curious concepts describing reflexology:

The purpose of the nerves is to carry messages and instruct the body. When the nerves improve that instruct the body, the instruction has to improve, the body has to improve. Every nerve in the body begins and ends in the hands and feet. By applying this specialized exercise pressure on the foot, the outcome is improved instruction to each and every part of the body, resulting in a re-educating, a re-patterning, and a re-conditioning of the nerves& instruction through the reflex/neutral electrical system of the body…also every lymphatic vessel begins and ends in the hands and feet.

The hands and feet are crowded indeed. Safe to say that the basic premises of reflexology have no bearing in reality. There are not projections of the body onto the hands and feet. As I have mentioned in the past, when I was a child I thought the Broadway in Portland was the same Broadway in New York and that if I kept walking I would end up on the Great White Way. It is true, in a way, that the two Broadways are connected in the same way that the nerves in the foot are connected to the liver, but it takes more links to get from one to the other than to get to Kevin Bacon.

What can reflexologist treat? Near about anything; it depends only on the claim of the reflexologist. Like many SCAMs, reflexology can help all illnesses. I would not deny that it is relaxing and pleasant to have one’s feet massaged — er, reflexed? (Reflexologist emphasize they are not doing massage.) But does reflexology have any real effects on any pathological states? Besides sore feet? And, while we are on the topic, why doesn’t walking have the same effect as reflexology?

Reflexology has been tested in clinical trials. Here is an issue that really gripes my cookies, or maybe a severe case of jealousy re: alt med.

In the world of infectious disease, getting to test an intervention for human use is a long process. First they have to find a potential antibiotic, discover the chemical structure and mechanism of action. Then the antibiotic is tested against numerous strains of hundreds of pathogens to see if it works in the test tube. Then there are a variety of animal studies looking for safety and efficacy. Then graduated clinical trials, phase 1, phase 2, and, finally, phase 3, before the antibiotic is declared non-inferior to vancomycin in human soft tissue infection.

Reflexology, and all other alt med interventions, bypass all these steps and go straight to clinical trials. Someone can pull a therapeutic intervention out of, well, this is the SBM blog, let’s say thin air, yeah, thin air. They can pull an intervention out of thin air and the next thing you know, good money is being spent to see if it is effective, when, evaluating it on the basis of reality, it should have the same chance of being effective as more common substances found in, well, ‘thin air.’

So, ignoring the fact there is no reason to test the efficacy of reflexology, what has reflexology been found to be effective in treating? Almost nothing of note. It is not effective for post operative cortisol levels, head ache, asthma, post operative pain, cancer anxiety, irritable bowel syndrome, pregnancy edema, low back pain, ovulation, and multiple sclerosis. It seemed to help pre-menstrual syndrome — so says the abstract which, I’m sure, accurately represents an unbiased and flawless experiment — but it did not even seem to help menopause symptoms.

What a hodgepodge of diseases. I thought aspirin was the wonder drug that worked wonders. The alleged near universality of reflexology, and other alt med interventions, is staggering. Imagine an antibiotic that not only treated all viruses, bacteria, fungi, and parasites but also infertility, headache, dementia and post op pain. Only alternative interventions have that kind of power. I am stuck looking for the underlying cause of a disease and targeting it with a specific intervention. How Western and reductionist of me.

While almost all individual studies show no benefit of reflexology, what would a systematic review reveal? The summation of nonsense, unfortunately, does not lead to validation of reflexology. Put all the small piles of nonsense together, you get one big pile of nonsense. The studies of reflexology are poorly done, with small sample size, and, not mentioned in the review, had no reason to be done in the first place.

Studies in breast cancer patients suggest to me that human contact is what it important, not the specific modality.

PATIENTS AND METHODS: One hundred and eighty-three women were randomized 6 weeks post-breast surgery to self-initiated support (SIS) (comparator intervention), SIS plus reflexology, or SIS plus scalp massage (control for physical and social contact). Reflexology and massage comprised eight sessions at weekly intervals. The primary end-point was 18 weeks post surgery; the primary outcome measure was the Trial Outcome Index (TOI) of the Functional Assessment of Cancer Therapy (FACT-B) – breast cancer version. The secondary end-point was 24 weeks post surgery. Secondary outcome measures were the Hospital Anxiety and Depression Scale (HADS) and the Mood Rating Scale (MRS).

RESULTS: At primary end-point, massage, but not reflexology, was significantly better than SIS on the TOI. Reflexology and massage were both better than SIS for MRS relaxation. Massage was better than reflexology and SIS for MRS easygoingness. At secondary end-point, reflexology, but not massage, was better than SIS on the TOI and MRS relaxation. There were no significant differences between reflexology or massage. There were no significant between group differences in HADS anxiety and depression. Self-reported use of out of study complementary therapies indicated that this was unlikely to have a significant effect on findings.

Or this one:

…significant decrease in anxiety observed in this sample of patients with breast and lung cancer following foot reflexology suggests that this may be a self-care approach to decrease anxiety in this patient population.

Or in the demented:

The findings demonstrate that when receiving the reflexology treatment condition, as compared to the control condition, the residents demonstrated significant reduction in observed pain.

All groups whose underlying disease leads to less human contact. Have you hugged your demented, cancerous nursing home patient today? I didn’t think so.

Monkeys, and other animals, groom each other often with a marked reduction in stress. Touch is good, and one doesn’t need to wrap it up in pseudoscientific nonsense for it to beneficial. Well, maybe you do. Strange people offering to massage your feet because it feels good may be off-putting for some and could lead to the authorities being involved.

One doesn’t need the woo of reflexology (projected maps and altered qi) to recognize that people need and benefit from physical interactions. Like in the NEJM recently, demonstrating the tai chi was of benefit in fibromyalgia. Exercise helps fibromyalgia, and tai chi is a gentle form of exercise, so it’s no surprise tai chi was of benefit; so is yoga. The mystical magic adds nothing.

Oddly, no one seems to have tested reflexology as an intervention for foot pain, a common complaint, and reflexology could not decrease foot edema in pregnant females. One wonders, if reflexology can’t even help a foot problem, what good is it?

The irritable bowel syndrome study concludes

I want to conclude with a note of caution. Although the results of this study are quite clear, they should not be used to dismiss reflexology as a treatment option across the board, nor indeed to argue against the effectiveness of CAM as a whole. The simple fact is that we know very little about the effectiveness of very many treatment options in relation to very many conditions. Reflexology in particular remains not just under-researched but almost unresearched, something that is quite startling given the extent of its use.

This is somewhat mirrored in the systemic review:

…the paucity and the poor quality of the existing studies prevents definitive judgement about the value of reflexology.

Well, technically, that’s true. But there is more than sufficient understanding about the workings of the human body to render a definitive judgement on reflexology. It won’t work because it can’t work, in much the same way that we know that a perpetual motion machine won’t work because it can’t work. And yet people keep inventing perpetual motion machines. Just because the rules of the universe say something is impossible doesn’t stop them from trying.

The great majority of studies demonstrate reflexology had no effects that could not be replicated by beyond picking fleas off your mate (am I over sharing?). And it has no anatomic or physiologic justification.

Years ago I was at a conference and one of my attendings was being detailed about a new antibiotic. The rep concluded with “and it’s very popular in Europe” to which my attending responded “so was fascism” and strolled off. Popularity is not a good justification to spending money and wasting patient’s limited time with nonsense.