Cardiff Metropolitan University
Prifysgol Fetropolitan Caerdydd
B.Sc.(Hons) Complementary Healthcare
The effect of reflexology on blood glucose levels and quality of life in adults
with diabetes mellitus type 2
May 2017
Dissertation submitted in partial fulfilment of the requirements of
the Cardiff Metropolitan University for the degree of Bachelor of
Science
1
Acknowledgements
I would like to thank all the degree programme tutors for their support over the last few
years, and for making this degree enjoyable and challenging in equal measure. A special
thank you to Judith for her enthusiasm and advice for this project.
I would like to thank my partner Jon for his patience, moral support, and for listening to me
go on and on about this project for the last year.
Thank you also to Natalie, one of my closest friends, whose support has been invaluable.
I am very grateful that my 4 participants so willingly volunteered to be a part of this study
and would like to thank them for their commitment to the study. They’ve been a joy to work
with.
Finally, my thanks go to the Health Psychology Research team at Royal Holloway,
University of London for their permission to use their ADDQoL questionnaire in this study.
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Abstract
Background
No research is currently available relating to the effect of reflexology on blood glucose
levels or quality of life specifically in adults with diabetes mellitus type 2 who manage their
condition without medication. Research suggests that reflexology, in conjunction with
conventional medication, may assist glycaemic control and may improve quality of life in
diabetics with neuropathic pain.
Research Question
What is the effect of reflexology on blood glucose levels and quality of life in adults with
diabetes mellitus type 2?
Method
An experimental study with 4 participants, primarily using quantitative data, supported by
qualitative. Participants received weekly reflexology treatments over a six week period.
Random blood glucose levels were monitored before/after each treatment and quality of life
at the beginning and end of the study.
Results
Some reduction in blood glucose levels was observed though significance cannot be
assumed. Results show a decline in general and diabetes-specific quality of life.
Conclusion
No conclusions regarding efficacy of reflexology can be drawn or significance of results
assumed, due to sample size and methodological limitations. A mixed methods approach
was advantageous for clarity of understanding. Further research is recommended with a
larger sample size and robust controls for external confounding variables.
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1.0 Introduction
Diabetes mellitus type 2 (DMT2) develops due to the inability of the body to use insulin
effectively, through insulin resistance or impaired pancreatic insulin production, and is
characterised by increased levels of blood glucose. (NICE, 2016).
World Health Organisation (2015) figures inform that diabetes is on the rise. In 2014 the
percentage of the worldwide adult population with the condition, diagnosed and
undiagnosed, was estimated at 8.4%, 7.3% within the European region, an increase from
1980 of 4.7% and 5.3% respectively (WHO, 2016). Nationally, across Wales, there has
been an increase in diagnosed adults from 5% in 2004 to 7% in 2015 (Welsh Health
Survey, 2015), and is estimated to cost 10% of the National Health Service (NHS) budget
(Hex et al, 2012). Global statistics for the breakdown into specific varieties of the diabetes
condition do not currently exist (WHO, 2016), although type 2 is considered to account for
approximately 90% of cases (Zimmet et al, 2001).
DMT2 is a progressive, degenerative condition where the longer an individual has the
condition, the greater the risk of developing serious health complications such as cardiac
dysfunction (Jorgenson et al, 2016), renal failure (Dart et al, 2012), retinopathy (Jin et al,
2014) and peripheral neuropathy (Nisar et al, 2015) and recent research also suggests that
diabetics are at increased risk of cognitive dysfunction.
Following diagnosis individuals need to closely manage blood glucose levels, through
lifestyle change and sometimes glycaemic control medication, which may result in impaired
perception of state of health and general wellbeing ie health-related quality of life (Shim et
al, 2012)
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Li et al (2004) suggest that even short term treatment which normalises blood glucose
levels can result in lower risk of reoccurrence of glycaemic control dysfunction in some
DMT2 patients, (Li et al, 2004), and where blood glucose levels are maintained within a
normal range the risk of co-morbid conditions may be prevented or delayed (NICE, 2015).
There is therefore merit in identifying low risk accessible treatments that can assist in the
management of blood glucose levels and improve quality of life.
Reflexology is considered a safe, non-invasive intervention (Hull, 2011). Reflexologists
believe that by using specialised techniques across reflexes in the feet, which correspond
to body organs and systems, normalisation of function may be achieved (Marquardt, 2007)
Reflexology, in conjunction with medication, has been found to have a positive effect on
blood glucose levels and quality of life in diabetic adults (Dalal et al, 2014). This study, will
therefore, investigate the effect of reflexology alone on blood glucose levels and quality of
life in adults specifically with diabetes type 2, managing their glycaemic control through diet
and exercise alone.
2.0 Review of literature
A comprehensive electronic and manual search was conducted at Cardiff Metropolitan
University and Cardiff University (Appendix 1) libraries, to access literature in the English
language, published in the last 5 years with relevance to this study. Where an older
relevant article was identified and no recent information existed, the original article was
sourced and utilised. Electronic databases searched included the Cochrane Library,
Science Direct, OvidSP, CINAHL and Google Scholar, the manual search focussed on
subject-specific publications and journals. Searches included the following keywords:
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‘Reflexology’, ‘reflex zone therapy’, ‘foot massage’, ‘diabetes’, ‘blood glucose’, blood
sugar’, ’complementary therapies’, ‘CAM’.
2.1 Glycaemic control
Stanfield (2014) defines glycaemic control as the regulation of blood glucose levels within
the body. Tissues and cells absorb glucose as the primary source of energy, required to
function effectively. Too much or too little glucose however can cause dysfunction
therefore levels need to be maintained within a narrow healthy range (see below). Glucose
absorbtion and blood level homeostasis is facilitated by insulin.
Table 1: Blood Glucose levels in non-diabetics
Fasting
4.0 – 5.9 mmol/l
2-hr post prandial
≤ 7.8 mmol/l
This is 2 hours following a
75g carbohydrate loading
(WHO, 2016)
*IDF (2016)
When dysfunction occurs and homeostasis is not maintained this can result in blood
glucose levels above the healthy range. If this occurs repeatedly it is classified as
hyperglycaemia, which is the primary characteristic in the diagnosis of diabetes mellitus
type 2 (DMT2). DMT2 is diagnosed where on more than one occasion one of the following
occur: (WHO report, 2016)

fasting blood glucose levels (FBG) ≥ 7.0 mmol/l

postprandial *2-h blood glucose levels (PBG) ≥ 11.1 mmol/l or

HbA1c levels of ≥ 6.5%
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Ju et al (2014) suggest that Hb1Ac is the best indication of glycaemic control as it
represents the average blood glucose level over the past 6-8 weeks, whilst FBG and PBG
are susceptible to daily fluctuation.
2.1.1 Pathophysiology of DMT2
Until recently development of DMT2 was generally considered to develop, in those
genetically predisposed, due to the dysfunction of a single regulatory mechanism where
insulin production from β cells in the islets of Langerhands of the pancreas is insufficient
(Figure 1) (Stanfield, 2014).
Dysfunctional blood glucose regulation in DMT2 (traditional view)
Figure 1: Schwartz et al, 2013
However more recent findings, mainly from animal experimental research highlighted the
role of a second regulatory mechanism involving the brain and autonomous nervous
system (Figure 2). Schwartz et al (2013) back this view for genetically predisposed
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humans too, and suggest that DMT2 occurs only when both regulatory mechanisms
become dysfunctional.
Two-fold regulatory process of blood glucose levels in hyperglycaemia
Figure 2: Schwartz et al,
2013
DeFronzo et al (2014) identified that DMT2 results in homeostatic imbalance in the brain as
well as many other organs. Kuritzky et al (2011) highlights that the level of metabolic
incretin hormones, which encourage insulin secretion, are low as a result of DMT2, hence
creating a lack of homeostasis in the gastro tract, exacerbating the diabetes condition.
Vagal activity is generally lower in diabetics also, resulting in a higher instance of
sympathetic nervous activity (Ju et al, 20).
Thus virtually all body systems and organs are involved and impacted by DMT2.
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Key systems that contribute to DMT2
Pancreas
Brain
Gut
Fat cells
Kidneys
Muscles
Liver
DeFronzo et al, 2014
2.1.2 Treatment - Oral glycaemic control medication - mechanism of action
In many cases oral medication is prescribed for the management of blood glucose levels
and these medications, such as Metformin, target several pathophysiological mechanisms
at once (DeFronzo, 2014), and can take up to four weeks to initiate (Kuritzky, 2011).
Therefore other treatments which offer management of symptoms, especially during this
phase, may be of interest to diabetics, and treatments that are able to address multiple
pathological abnormalities could be suitable (Cornell 2015).
2.2 Psychosocial Factors that may affect DMT2’s blood glucose levels
Other external factors can also affect blood glucose levels, which can fluctuate throughout
the day (Campbell et al, 2003). With this in mind where comparisons of repeated readings
are required these should be taken at the same time of day to try and achieve consistency
(Campbell et al, 2003).
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2.2.1 Lifestyle factors
Research supports the view that lifestyle factors, such as diet, can affect blood glucose
levels. High consumption of carbohydrates can trigger glucose levels to rise whereas a
low-carbohydrate diet has less impact and is more manageable in DMT2 sufferers
(Fernemark et al, 2013).
Stress can cause an increase in blood glucose levels, most affecting those who have a
stronger emotional reaction to stress. Those with more resilience and a less emotional
response to stressors remain unaffected (Rook et al, 2016). The hormone cortisol,
produced by the adrenal gland as part of the body’s stress response, can decrease insulin
sensitivity, and hence contribute to hyperglycaemia (Fernemark et al, 2013)
Exercise is considered to have a positive impact on blood glucose levels, as it can increase
metabolic action. Angandi et al (2017) carried out a longitudinal study with 52 participants
to investigate the effects of regular yoga practice on blood glucose levels in type 2
diabetics. FBG and PBG levels were tested using an oral glucose tolerance test at
baseline, and the end of months 1,3 and 6. HbA1c tests were carried out at baseline and
the end of 3rd and 6th month and suggested a positive impact on glycemic control. Analysis
via a paired sample t-test showed significantly lower HbA1c % in individuals who had
completed the schedule of classes at the end of month three, compared to baseline, and
identified a trend towards lower FBG for the participants with the higher level of attendance
at classes, although this was not statistically significant (mean: 165.88, SD 42.77, p =
0.08).
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Glycaemic control medication, as an external variable, may also have influenced blood
glucose results in the study by Angadi (2017), as the participant group consisted of
individuals with varying severity of DMT2, some of whom were prescribed medication.
2.2.2 Psychological factors
As well as lifestyle and behavioural factors Garcia-Perez et al (2013 HC) found that
adherence to therapies in patients with DMT2 can be impacted by personal beliefs or fears,
and Warren et al (2012 HC) suggest that a feeling of regaining control can positively affect
glycaemic control.
2.2.3 Identifying influencing factors – a mixed methods approach
Whilst being aware that external factors can impact blood glucose levels is helpful, it can
be challenging to identify their influence, or in the case of designing a research study, to
implement suitable controls (Teddlie & Tashakkori, 2009), however if we are unable to
collect information regarding these factors vital clarification of results may be missed
(Dieppe, 2013).
Whilst the quantitative data in Angandi et al’s (2017) study was of interest, relying on
quantitative statistics alone may result in relevant information being missed and results
unexplained. Angandi et al (2017) qualitative data were collected using semi-structured
interviews and implied that diet may have influenced blood glucose levels in some cases.
Participants were asked for diet information a month in arrears. This risked the presence of
recall bias in the study, due to the time lapse which may affect participants’ memory.
Collecting data more regularly during the study would alleviate this risk.
Using qualitative data to determine psychosocial influencers of health and illness adds
external reliability as it represents results more relevant to real life (Cochrane, 2013).
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Analysis of data by subgroup, also, could be advantageous to better understand and make
transparent the impact of external factors, eg lifestyle or medication, on research results.
A mixed methods approach is recommended for health services research (Fox, 2013).
Collection and analysis of narrative data can also encourage more open, honest discussion
and can offer insight into how the participant perceives their wellbeing. As with other
chronic conditions diabetes can impact quality of life.
2.3 Perceived Quality of Life in DMT2 sufferers
Quality of life is particularly important to sufferers of DMT2 (Abdelhafiz et al, 2013).
Findings in a study with older people suggest that participants were more concerned about
their quality of life than blood glucose levels (Abdelhafiz et al, 2013).
Some research findings identified a negative correlation between blood glucose levels and
health-related quality of life, and that quality of life was associated with length of time since
diagnosis, where those who had been diagnosed under 5 years ago had a better quality of
life score than those diagnosed over 10 years ago (Shim et al, 2012). This was not the
conclusion of Canaway & Manderson (2013) who found no difference in association of
these two variables in a group of CAM-users compared to non-users. Increased quality of
life has also been associated with consumption of oral medication in situations where the
medication has effectively managed glycaemic control (Kuritzky, 2011). Quality of life is a
phrase that can mean different things to different people, therefore it is advisable to identify
the most appropriate tool to elicit information relevant each individual study (Shim et al,
2012).
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2.3.1 Measuring health-related quality of life
Shim et al (2012) advise that a disease-specific questionnaire is beneficial, especially in
the case of diabetes, as it better reflects the impact of the condition. To ascertain quality of
life in diabetics with neuropathy Dalal et al (2014) used a questionnaire specific to
neuropathic pain, and their findings suggest that this was advantageous to their study as it
enabled them to focus on the specific concerns affecting their participant base.
In their study Shim et al (2012) recruited 282 participants, over 21 years old who were
prescribed glycaemic control medication. Participants were interviewed in a cross-sectional
interviewer-administered survey study exploring health related quality of life. Two health
related questionnaires were used: Euroqol 5-D (EQ-5D) to measure generic health, and the
diabetes-specific instrument, the ADDQoL to assess the impact of their condition on quality
of life. ADDQoL is considered a good indicator of quality of life in sufferers of diabetes as
participant’s score not only the severity of a health domain, but also the importance to
them. Correlation between blood glucose, ie Hb1Ac, level and each quality of life
questionnaire was tested using Pearson’s product-moment test and findings suggested a
significant but weak negative correlation with both (both r = -0.2, P = 0.001).
Given the suggested association between perceived quality of life in diabetics and
improved health outcomes described above, ie better glycaemic control, quality of life
should be central when considering patient-centred options (Abdelhafiz et al 2013 HC).
Lui et al (2012) found that diabetics with a lower perceived diabetes-specific quality of life
were more likely to elect to use complementary and alternative medicine (CAM), usually in
conjunction with conventional treatment for their condition. Use of CAM has been
considered to improve the outlook of those with chronic conditions (Canaway &
Manderson, 2013)
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2.4 CAM and DMT2
CAM treatments which promote relaxation and symptom management are sought by some
DMT2 sufferers (Lui et al, 2012). Manual therapy treatments sought include acupuncture
(Ju et al, 2014).
An exploratory experiment to understand the impact of auriculotherapy, a type of
acupuncture, on blood glucose levels in participants diagnosed with DMT2 was undertaken
by Ju et al (2014). 71 participants undertook three months of daily auricular point
stimulation treatment, using specialized electronic equipment to stimulate the conchae
cavum point, associated with the vegus nerve. The researchers were interested to
investigate whether this treatment would increase vagal activity, in turn stimulate the
parasympathetic system and consequentially have an effect on blood glucose levels (Ju et
al, 2014). Auriculotherapy is described by Oelson (2007) as a therapy where stimulation of
auricular acupoints on the external surface of the ear, which represent zones or areas of
the body, can bring health benefits to that area of the body.
HbA1c, FBG and PBG levels were measured at the beginning and end of the study,
Following the intervention data were analysed in three subgroups; those taking no
glycaemic control medication (n=18), those with unchanged medication (n=46), those who
altered medication during the intervention (n=7). Mean blood glucose test results for the
un-medicated group suggest a significant reduction in Hb1Ac from 6.65% to 6.31% (p less
than 0.05). FBG and PBG levels both reduced but were not found to be significant (mean
FBG 6.37 mmol/L to 6.16 mmol/L; mean PBG 10.82mmol/L to 10.66 mmol/L). Thus
researchers concluded that this intervention may make a positive contribution to glycaemic
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control (Ju et al, 2014), however no consideration was given to the possible influence of
external factors thus limiting conclusions which can be drawn from the findings. A mixed
method approach would have offered more robust exploration of the research question.
Complementary therapy research experiments that specifically analyse and report data for
un-medicated type 2 diabetics are few, therefore this study contributes to an area that is
likely to become of increased interest as number of newly diagnosed with diabetes type 2
increases.
Lui et al (2012) recommend further investigation into the role of CAM in controlling diabetes
symptoms. In light of the auriculotherapy findings detailed above exploring other accessible
CAM manual therapies which are believed to evoke a strong vagal response may be useful
to increase client-centred treatment through increasing choice. Reflexology is often
described as relaxing which reflexologists believe is achieved through the holistic approach
of the treatment, encouraging homeostasis of the sympathetic/parasympathetic systems,
hence increasing vagal activity, as well as stimulation or sedation of the reflex points
specific to the health concern. Whilst the mechanism of action in reflexology therefore is
different to auriculotherapy both involve reaching body systems and organs through
assigned points in peripheral areas.
2.4.1 Reflexology and DMT2
Reflexology has been found to reduce blood glucose levels in diabetics with neuropathy
(Dalal et al, 2014).
Dalal et al (2014) conducted a six month open label random control trial (RCT) using a pretest post-test experiment with 58 medicated diabetic participants , split into two groups, a
15
reflexology intervention group (RIG) and a control group (CG), to examine their hypothesis
that “the stimulations generated by finger movements of reflexology areas would restore
homeostasis of the body organ functions and hence have therapeutic effect on diabetic
neuropathy”, with the expectation of a 40% better improvement in the perception of pain in
the RIG than the CG. The RIG received conventional pharmacological treatment and
weekly thirty minute reflexology sessions from their caregivers, the CG received
conventional pharmacological treatment alone.
Perception of neuropathic pain was measured using a visual analogue scale (VAS) and
secondary measures including FBG and PBG level readings were monitored at baseline
and follow-up stages. A paired t-test was conducted and found blood glucose measures to
be statistically significant in both groups (Table 2).
Table 2: Blood Glucose Level Results
Measure
Reflexology Intervention Group
Control Group
Hb1Ac
9.7% baseline 6.4% follow-up, p=0.001
9.4% baseline, 8.6% follow-up, p=0.001
FBG
160.2 mg/dL baseline
153.4 mg/dL baseline
109.6 mg/dL follow-up, p=0.001
130.7 mg/dL follow-up, p=0.001
230.0 mg/dL baseline,
220.8 mg/dL baseline
141.0 mg/dL follow-up, p=0.001
178.7 mg/dL follow-up, p=0.007
PBG
Dalal et al, 2014
Findings therefore suggest that regular reflexology treatments in conjunction with
conventional medication may reduce blood glucose levels in diabetics with neuropathic
pain.
They acknowledge that there are some limitations of the study, such as using untrained
caregivers to deliver reflexology, and mainly doing so off-site. They have endeavoured to
16
mitigate any risks to treatment consistency by putting compliance actions in place; an
instruction sheet with a routine to follow, some sessions carried out at the lab and observed
by independent clinicians. As all participants were recruited from one single community
results cannot be generalized therefore researchers recommend that future studies are
larger also include participants of difference communities.
2.4.1.2 Reflexology and Quality of Life
Findings of a random control trial by Dalal et al (2014) identify that the reflexology
intervention reported a 21.3% significantly better improvement in quality of life than the
study control group (p=0.001, 95% confidence interval). Reflexology has also been shown
to improve quality of life in some other chronic conditions, such as rheumatoid arthritis (RA
paper). Taha et al (2011) consider that reflexology could prove effective for improvement in
quality of life in a wide range of conditions, including diabetes, and that further research to
investigate this should be encouraged.
Lui et al (2014) support this view and conclude that with the rising incidence of DMT2
further research should be undertaken to explore how CAM treatments can assist in the
management of diabetes, which may potentially benefit glycaemic control, diabetic
symptoms and quality of life.
2.5 Summary of literature review
The literature reviewed suggests that reflexology in conjunction with medication can assist
glycaemic control in diabetics, however does not address its efficacy in type 2 diabetics
who manage their condition without medication. It also informs that a whole-body
treatment approach is appropriate.
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CAM research with auriculotherapy highlights some, although not significant, beneficial
outcome results for blood glucose levels in un-medicated type 2 patients. Whilst there is
some difference in mechanism of action compared to reflexology both include the concepts
of stimulation of points relating to body systems, therefore raises the possibility for some
impact through reflexology.
It is clear from this review that the best measure of glycaemic control is Hb1Ac test,
however this requires a blood test, which is beyond the realms of an undergraduate
project, therefore blood glucose tests will be undertaken with consideration given to the
points raised. To endeavour to explore any trends in blood glucose changes, this study will
carry out weekly reflexology treatments over a six week period, which is seen as
achievable within the confines of this project. Six weeks is also considered appropriate by
the author as the review clarifies that participants gain most benefit when changes to
Hb1Ac are realised, which require 6-8 weeks to take effect. Whilst this cannot be measured
in this study it may allow participants to achieve maximum benefit, in the event that any
positive blood glucose changes occur.
To add to the validity of a study there needs to be an acknowledgement in the methodology
to take into account the influence of external variables, as blood glucose levels are highly
susceptible in particular to diet, exercise and stress therefore blood glucose readings will
be taken before and after each treatment.
The review highlights that the numbers alone cannot fully explain results, and that
qualitative data adds clarity and insight to assist in drawing conclusions, therefore a mixed
methods approach will be undertaken.
The review suggests that health-related quality of life is important to diabetics, sometime
more so than diabetic symptoms, and that reflexology may have a positive impact on the
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quality of life in this client group. It is also advantageous to use both generic and diabetesspecific health related quality of life measures to capture all aspects of wellbeing.
Aim of this study
With this review in mind the aim of this research project is to investigate the effects of
reflexology on blood glucose levels and quality of life in adults with un-medicated diabetes
mellitus type 2.
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3.0 Method
Introduction
The methodology used was a single-subjects experimental exploratory design with 4
participants to investigate the effects of reflexology on blood glucose levels and quality
of life in adults with dmt2 who manage their condition without medication. Using a
mixed methods approach with quantitative data supported by qualitative data for
enhanced clarity and understanding. Mixed methods approach is appropriate when
trying to build a more comprehensive understanding of what is occurring (Teddlie &
Tashakkori, 2009). This study is carried out within the time and resources constraints
of an undergraduate project.
Design
This was a single-subject, non-blinded quasi-experimental design where repeated
measures are used in a pre-test post-test approach:
Baseline phase (A1): Initial measurement of the dependant variables; random blood
glucose level and quality of life.
Intervention Phase (B): Over a 6 week period the independent variable, a weekly 40
minute reflexology treatment, was carried out and dependant variables observed.
Follow-Up Phase (A2): Supporting qualitative data collected and a passive control
phase during which the dependant variables were observed. The passive ‘notreatment’ control is included where blood glucose level readings will be taken at a 40
minute interval, ie the same time as during the intervention phase. Comparisons were
made between data taken at baseline and end of study, and before and after
treatments.
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Table 3: Research Study Schedule
Week
1
2
3
4
5
6
7
Activity
Baseline meeting
Intervention 1
Intervention 2
Intervention 3
Intervention 4
Intervention 5
Phase
A1
B
B
B
B
B
B
Random
Blood
Glucose
Level







ADDQoL
Questionnaire
MYMOP
Initial
Form
MYMOP
Follow-up
Form
Semistructured
Interview


Intervention 6
Follow-up meeting
Includes a
no-treatment
control
blood glucose
8 reading
A2


Note: Each  represents one instance of the measure 195






Participants
Recruitment and sampling
Four participants were recruited using convenience sampling. Agreement was granted
to place a poster in the Podiatry Clinic of Cardiff Metropolitan University (Appendix x).
The poster was also uploaded to the researchers personal facebook account and
shared with friends and contacts of friends. The first 4 individuals who met the criteria
(see below), and were available for the full period of the study were included.
Inclusion Criteria
All participants met the following criteria:
 Aged 18-76 years

Diagnosed with diabetes mellitus type 2 over 6 months ago

Managing their condition through diet and lifestyle alone
Exclusion Criteria
Participants who met any of the following were excluded from the study:
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
Diagnosed with a secondary condition caused by their diabetes; such as
neuropathy, cardiovascular disease, retinopathy, nephropathy.

Recent hypoglycaemic episode as a result of blood glucose fluctuation

Recent surgery

Pregnant

Currently consulting a medical professional for any other serious health condition
for which reflexology may be considered contraindicated, eg. deep vein
thrombosis.
Data collection
A multi-level parallel mixed methods approach to data collection allows for metainferences from quantitative and qualitative data (Teddlie & Tashakkori, 2009).
Baseline
Intervention
Follow-up
Quantitative
Random Blood Glucose Level
ADDQol Questionnaire
Quantitative
Random Blood
Glucose Level
Quantitative & Qualitative
Quantitative
Random Blood Glucose
Level
ADDQol Questionnaire
MYMOP Form
Qualitative
Semi-structured
Interview
Figure x: Parallel data collection
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Data Collection Tools
Accu-Check Nano Performa Monitor: Random blood glucose levels (RBG)
Blood glucose levels for a participant are taken at the same time each time to ensure
consistency with repeated readings of the dependant variable (Robson, 2011, p202).
RBG readings do not require any fasting or diet regime.
The Nano Performa is a specialised monitor for measurement of blood glucose levels
in mmol/l. The tests are not classified as official medical readings, these are carried
out by a GP at regular health check appointments. Participants used their individual
lancet equipment, however all readings were taken on the same monitor to avoid any
discrepancy with different machines.
Audit of Diabetes-Dependent Quality of Life (ADDQoL)
ADDQoL is a diabetes-specific questionnaire which measures an individual’s
perception of the impact of their condition on their health. It includes nineteen items
relating to all areas of life, eg family life, social life, dependence on others, financial
situation, physical appearance, freedom to eat as they like. Respondents evaluate how
different the item would be in the absence of their condition, and how important it is to
them. It is comprehensive in evaluating the quality of life in adults with diabetes (Ostini
et al, 2012)
Measure Yourself Medical Outcome Profile (MYMOP)
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Paterson (2004) describes MYMOP as a “patient-generated, problem specific
questionnaire” that measures up to 2 symptoms, identified by the client as important,
on a 7 point scale ranging from 0 ‘as good as it could be’ to 6 ‘as bad as it could be’.
MYMOP is highly sensitive to change and particularly effective where clients present
with a variety of symptoms (Hull et al, 2006).
Semi-structured Interview
At the end of the study a brief face-to-face conversation was undertaken, using two
pre-determined questions, detailed below, to obtain feedback about participants’
experiences and to identify any common trends or themes.
Interviews were audio
recorded
Questions:

I’m very interested in your experiences during this study, can you please tell me about
them.

Can you please tell me about any other information you feel is relevant.
Equipment
The following equipment was used by the researcher during the study
Baseline Meeting
Treatments
Follow-up meeting
2 chairs
Pen
Paper
Blood glucose monitor
1 Blood glucose test
strips
Tissues
Reflexology recliner
Stool for therapist
Blankets and cushions
2 Towels
Wipes
2 chairs
Pen
Paper
Audio recorder device
Blood glucose monitor
Anti-bacterial gel
Participation
Information sheet
Un-fragranced foot cream Pen
2 Blood glucose test
strips
Tissues
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2 Consent forms
2 Blood glucose test strips
Consultation form
Tissues
ADDQoL questionnaire
ADDQoL
questionnaire
Interview question
sheet
Relaxation music cd
Music CD Player
Blood glucose monitor
Reflexology treatment record
sheet
Relevant MYMOP form
Procedure
Prior to the baseline phase the researcher contacted all respondents by telephone to
provide details about the study and ascertain suitability for inclusion against the inclusion
and exclusion criteria. If suitable, a face to face meeting was arranged at a mutually
convenient time.
Baseline Phase
Information was given verbally about the study timescales and process, including specific
details relating to: Aims of the study, Voluntary involvement, Withdrawal without providing
any reason up to the data analysis stage, Outcome measures, Reflexology treatment
procedures and risks.
Participation Information Sheet provided (Appendix x), explained and any questions
answered. These actions were taken following verbal consent:

Completion of consultation and consent forms (Appendices x and x respectively)

Completion of ADDQoL questionnaire

Random Blood Glucose (RBG) reading obtained

Appointments agreed for the following 7 weeks to take place on the same day/time.
25
Intervention Phase
Immediately prior to each treatment feedback was obtained about: experiences following
the previous session, brief health update, time and content of last meal, exercise
undertaken. Answers were recorded on the Reflexology Treatment Record (Appendix x). A
RBG reading was obtained and recorded on the treatment record and MYMOP form
completed.
Participants removed all footwear, were made comfortable in the reflexology recliner, and
received 40 minutes reflexology treatment in line with Reflexology Treatment Procedure
Sheet (Appendix x)
Immediately following each treatment a RBG reading was obtained and results recorded on
the Reflexology Treatment Record, water offered and client-specific aftercare advice given.
A verbal check was made to ensure the client was fit and healthy to travel prior to leaving.
Follow-up Phase
A RBG reading was obtained, ADDQoL questionnaire completed, semi-structured interview
undertaken and, 40 minutes after the first test, a second RBG reading obtained. The
researcher thanked the individual for their participation in the study and offered them the
opportunity to meet at a later date to view the completed research document.
Ethical considerations
Ethical approval was granted by the Cardiff Metropolitan University School of Health
Sciences ethics committee on 24th November 2016 (Appendix x).
Cardiff Metropolitan authorised written consent forms were completed at baseline meeting.
The therapist is qualified in Level 5 Reflexology, fully insured, holds a current First Aid
certificate and undertaken a government Disclosure and Barring Service check.
26
Prior to study commencement the researcher obtained the Diabetes UK, Diabetes in
Healthcare certificate via an e-learning programme accredited by the Royal College of
Nursing, for healthcare professionals dealing with clients with diabetes.
Data Security
Personal data collected during the study was kept confidential, with participants’ names
substituted with a client code for protection of anonymity. All data was stored securely in a
locked cabinet at the researcher’s home address. Any electronic data was kept on a
password protected computer in accordance with the Data Protection Act 1988.
Data analysis
Data collected were primarily quantitative, supported with qualitative data. Microsoft Excel
was used to organise, calculate and to create graphs for visual representation of group and
individual data for all quantitative measures to aid analysis. Statistical Package for the
Social Sciences (SPSS), version 23, was used for descriptive and inferential statistical
analysis.
Quantitative data
Shapiro-Wilks check suggested the random blood glucose level data were normally
distributed (Appendix x), however this could not be assumed as this test is unsuitable for
small samples which may pass the normality test incorrectly (Ghasemi & Zahediasl, 2012).
Normality was therefore not assumed and non-parametric tests undertaken. Mean and
standard deviation for RBG data were calculated via SPSS, and presented in an Excel
table.
Using SPSS the Sign Test was conducted to test for significance in:
27

RBG levels at the beginning and end of the study, ie baseline and follow-up phases

RBG levels before/after each reflexology treatment and for the control ‘no treatment’
readings

ADDQoL overall quality of life score (ordinal data)

MYMOP profile and wellbeing scores at the beginning and end of the intervention
phase.
This test is used in this study to calculate the probability over and above that of chance, of
an event occurring in repeated measures. This test is suitable for use with repeated
measures for single sample and is appropriate for small samples of under 6 (Field, 200x).
Spearman’s test for correlation was conducted for the above data also, to test for a
correlation between reflexology as the independent variable and the dependant variables,
RBG levels, client-specific symptoms and general wellbeing (MYMOP), and diabetes
specific quality of life (ADDQoL).
The study hopes to ascertain from these tests whether or not the cause of any change can
be attributed to reflexology.
Qualitative data
Manual content analysis was carried out on the semi-structured interview transcripts and
any the qualitative data provided during treatment feedback or MYMOP forms and
presented in a MS Word table for trends and themes. Quotations are used as required to
aid analysis.
28
4.0 Results
4.1 Participants
There were 4 female participants in this study aged between 46 and 76 years old. All have
been diagnosed with diabetes mellitus type 2 by their GP, none require glycaemic control
medication, managing blood glucose levels through lifestyle, ie diet and exercise. The
study comprised weekly reflexology treatments for six week, all participants completed the
study in full.
Table 4 : Participants Profile
Client Ref
Age
Occupation
Glycaemic Control (SelfRated)
S1
46 years old
Bio-Scientist
Average
JT2
68
Retired
Average
J3
62 years old
Retired
Good
K4
76 years old
Retired
Good
An overview of group results is provided for all outcome measures, followed by individual
results for each participant. Results are reported as follows:

Random blood glucose readings

Measure Yourself Medical Outcome Profile (MYMOP)

Audit of Diabetes –Dependant Quality of Life Questionnaire (ADDQoL)

Semi-structured interview
29
4.2 Mean Blood Glucose Results for Participant Group
n=4
Random blood glucose
before
Random blood glucose
after
Difference
Binomial test result (SPSS)
Spearman’s rho (SPSS)
Significance (SPSS)
T1
T2
T3
T4
T5
T6
CONTROL
9.3 ± 1.6
8.8 ± 1.2
8.8 ±
0.7
7.1 ±
1.0
7.1 ±
1.0
6.2 ±
0.4
7.0 ± 1.0
8.4 ± 1.4
8.2 ± 1.9
9.8 ±
1.5
6.5 ±
1.6
6.7 ±
0.7
5.8 ±
1.1
6.4 ± 0.8
-0.9
-0.6
1.0
-0.6
-0.4
-0.4
-0.7
1.00
0.63
0.13
1.00
1.00
0.63
0.63
0.40
1.00
1.00
0.80
0.63
1.00
0.63
0.60
0.01
0.01
0.20
0.37
0.01
0.37
Random Blood Glucose Readings Results
Table 4 above details the mean and standard deviation (mean ± standard deviation) for
random blood glucose level results for all participants before and after seven sessions, the
six reflexology interventions and the one control no-treatment meeting. The difference of
the readings is also displayed.
A sign test was conducted using SPSS (Appendix x) and returned 2-tailed binomial test
results detailed in the table. This analyses the results against a null hypothesis of 0.5, so in
this case that is an expectation that purely by chance 50% of the readings could result in a
decrease in blood glucose level (ie an equal chance of readings going up or down).
The results suggest that in treatments 1,2,4,5,6 and the control ‘no-treatment’ session, the
number of instances of reduced blood glucose level readings is higher than the expected
0.5, 50% (T1 p = 1, 100%; T2 p= 0.63, 63%; T4 p= 1, 100%; T5 p= 1, 100%; T6 p=0.63,
63%; Control p=0.63, 63% (all 2 sided)). In treatment 3 the number of reduced blood
glucose level reading instances was lower than the expected 0.5 (p=0.13, 13% (2 sided)).
The binomial test result for baseline compared to follow-up for a decrease in blood glucose
levels is higher than the expected 0.5, 50% with p=0.63, 63% (2-tailed).
30
In the no-treatment control session the average amount of change in before/after blood
glucose readings, in either direction, was 0.7 mmol/l.
In relation to reflexology interventions a difference of more than this observed only in
treatments 1 and 3 (T1 decrease of 0.9, T3 increase of 1.0).
Spearman’s rho test returned a statistically significant positive correlation between
reflexology and RBG levels for treatments 2,3 and 6 with identical results for all of these
cases, rho = 1.00, p=0.01. This suggests that there may have been a correlation between
the reflexology and the change in RBG levels in these instances.
Mean Random Blood Glucose levels Before & After
with Trendline and Difference line
12.0
10.0
mmol / l
8.0
6.0
4.0
2.0
0.0
-2.0
Treatment 1 - 6 and Control
Random blood glucose before
Random blood glucose after
Difference
Linear (Random blood glucose before )
Figure 3 displays the bar chart representation of the mean blood glucose level results in
This shows a downward trend across duration of the study so the mean RBG level at the
follow-up phase was lower than at baseline.
31
The difference line shows that there was a larger difference, a 1.0 increase, in the
before/after blood glucose measurements at treatment 3. The trend of the ‘after
intervention’ results across the study are represented by a trend line and the ‘difference
line’ displays the mean difference in the before and after results for each session.
32
MYMOP
Figure 4: Mean MYMOP Profile and Wellbeing scores
Mean MYMOP total score and wellbeing
MYMOP rating
3
2.5
2
1.5
T1
T2
T3
T4
T5
T6
T
reatment
Symptom Score
wellbeing
Figure 5 identifies a profile score improvement of 0.75 from treatment 1 to treatment 6. This
indicates an improvement in participants’ perception of health-related quality of life.
The Wellbeing rating has increased from 2 to 2.25, indicating a reduction in perceived
general wellbeing.
33
ADDQoL
Mean scores for general quality of life and general diabetes impact scores before
and after baseline
General quality of life and general diabetes impact at baseline and
followup
2
1.5
1
0.5
0
-0.5
-1
-1.5
General
QoL
Baseline
General
QoL
Followup
General
Diabetes
Impact
Baseline
General
Diabetes Impact
Followup
This represents the mean scores for the 2 self-perceived overview questions, and
highlights a decline in general quality of life (1.5 baseline, -0.5 follow-up).
It also shows that the Diabetes Impact score has changed from 1.5 at baseline to -1.0 at
follow-up, suggesting that participants perceive their diabetic condition to have a more
negative impact on their quality of life at the end of the study than at the start.
34
ADDQoL Questionnaire – Diabetes impact questions total score – do a mean graph
for the questions 1-19
Mean weighted scores for each question
Freedom to Drink as I wish
Freedom to Eat as I wish
Depend on Others
Living Conditions
Financial Situation
Feelings about the Future
Other people's reaction
Motivation
Self-confidence
Physical Appearance
Sex Life
Close Personal Relationship
Friendships/Social Life
Family Life
Physical Ability
Holidays
Journeys
Work Life
Leisure Activities
-4.5
-4
-3.5
-3
-2.5
Followup
-2
-1.5
-1
-0.5
0
Baseline
At baseline the life-areas rated as most negatively impacted by diabetes was ‘freedom to
eat as I wish’, ‘the need to depend on others’ and ‘holidays’.
At follow-up these were ‘freedom to eat as I wish’, ‘holidays’, ‘feelings about the future’ and
‘close personal relationships’. The perceived negative impact scores for ‘freedom to eat’
and ‘holidays’ became more detrimental at the end of the study.
Five life-areas at baseline were rated as being least impacted by diabetes: ‘leisure
activities’, ‘journeys’, ‘sex life’, ‘motivation’ and ‘other peoples’ reactions’. At follow-up the
areas rated as least impacted were ‘work life’, ‘physical appearance’ and ‘other peoples’
35
reaction’. The only life-area to remain unchanged in rating from baseline to follow-up
phase was ‘financial situation’.
Some life-area questions were not applicable to all participants, these are details in table 5
Table 5 Not-applicable questions by participant
Area
Work Life
Family life
Close personal relationships
Sex Life (Baseline)
Sex Life (Follow-up)
Participants
Applicable
S1
S1, JT2, K4
S1, JT2
S1
S1, JT2
Participants Not
Applicable
JT2, J3, K4
J3
J3, K4
JT2, J3, K4
J3, K4
Qualitative Interviews
Table of trends and themes including quotes
Main Topic
Relaxing
Intervention
Quotation
S1
I found reflexology so relaxing when I get home and I seem to sleep
better at nights.(JT2)
it is very nice and relaxing and something I look forward to (J3)
I love reflexology, it was lovely. It was very nice and very relaxing (K4)
Eating
I don’t think I have changed my eating habits at all, it is just watching
what I’m eating (JT2)
I probably have started to eat more(S1)
I can say whilst you were treating me I had one of the naughtiest periods
I have ever had and it didn’t show up (J3)
when I was on holiday at one point I didn’t eat when I should of and in
the past I have gone wobbly one week and it just didn’t happen and I
thought “Wow” that is weird (J3)
Sometimes I thought I knew I hadn’t been as firm on my diet as I should
have been and sometimes I’ve felt I have done so good but then the
readings have been up and I can’t understand it (K4)
36
…. I have a different view of an eating regime of a diabetic person. I
knew the basics like fat and sugar are not what you eat and it goes
further than that and I found I have been thinking about them as I have
been having the blood tests (K4)
Comment
about blood
glucose
levels
the thing is from the time that I started they were very high and then they
came very low (JT2)
I am quite astonished that um the last few readings have been so
low!”….. “I don’t think I have ever had readings in the fives.” (S1)
I thought I was just going to get some nice reflexology and it actually
seems to work out that my blood sugar has actually improved which has
outstanded me no end….. every reading seems to of gone down over
the 6 weeks both from the beginning and the ending of the treatment
and getting in the end of 6 weeks. Especially after times when I have
been a naughty girl and it hasn’t shown up at all. I think you have cured
me.”
(J3)
yes they were very different because the times I expected it to be lower
it would be higher and that is the understanding bit that I couldn’t quite
get the jist of it all.” (K4)
Any adverse
reaction
I would say that initially my general thought was that my wellbeing went
downhill and I was sort of looking forward to it stopping at that point.
Once I learned that my blood pressure was going down I began to forget
about that and was really pleased (J3)
I was hoping that I would be sleeping better with the reflexology as I had
heard others saying it, but it certainly hasn’t happened with me (J3)
“my first experience of the study was a bit trepadacious. I did have a bit
of concern with what was going to come up from the research. Now I am
both perplexed and very interested in what has happened” (K4)
Would
consider
continuing
reflexology
if I had the choice I would continue because I do genuinely feel better
since having it (S1)
Noticed a
difference in
my back has been really sore but with the reflexology I have been able
to sleep better (JT2)
my verruca’s have improved (S1)
I think I would be willing to pay for a treatment once a month if I thought
that was really going to affect my blood sugar levels and to keep it in
that state I probably would pay once a month (J3)
37
non-diabetes
symptoms
I also have had a rash on my face for a few months before coming to
have a treatment and that improved, in the first week I had reflexology
and I had no change in that before the reflexology and it it improved and
then came back and improved (S1)
had issues with both of my hips at the start of the 6 weeks and that
seems to of cleared up in both of them and a dodgy knee that comes
and goes and I haven’t had much problems with that (J3)
Trends and themes from the qualitative interviews:

all participants enjoyed the reflexology treatments.

all were aware that the food they eat is linked to blood glucose levels.

2 experienced some adverse reactions over the course of the study, J3 and K4.

3 noticed some improvement in other non-diabetes relating symptoms, S1, JT2, J3

The 3 participants who saw a blood glucose reduction over the study S1, JT2, J3
attribute the change to taking part in the study.
Summary
There was a general trend in mean blood glucose level findings towards a reduction. In all
instances of pre-test, post-test monitoring blood glucose levels changed in some way,
either increasing or decreasing however no pattern emerged.
General quality of life showed a slight decline in both the ADDQoL and MYMOP Wellbeing
scores. Diabetes-specific quality of life declined slightly also, however the life-areas
perceived to be impacted most changed a little at baseline and follow-up. However,
individual MYMOP scores suggest an improvement in a range of non-diabetes symptoms.
Themes emerging from interviews identify that participants eating habits may have
changed and that participants attribute the change to taking part in the study, and some
associate changes directly to receiving reflexology.
38
5.0 Discussion
Introduction
The primary purpose of this quasi-experimental study was to investigate the effect of
reflexology on blood glucose levels in adults with diabetes mellitus type 2, who manage
their condition through diet and exercise alone. The secondary purpose was to investigate
the effect of reflexology on health-related quality of life in this client group. All four
participants were female, three of whom were retired therefore the study lacks diversity, all
participants remained for the entirety of the study.
A comprehensive review of previous English language literature found no evidence specific
to reflexology with un-medicated type 2 diabetic adults. A small body of literature in the
Chinese language exists, however translation was not available therefore these could not
be reviewed for relevance or suitability. Dalal et al (2014) suggest that reflexology in
conjunction with conventional medication may be considered effective in the management
of the symptoms of diabetes mellitus in individuals with diabetic neuropathy, and may have
a reducing effect on blood glucose levels in this client group. The study also suggested a
positive impact of reflexology on disease-specific quality of life.
Findings
Quantitative findings of the study raise the following points of interest:
 There was a reduction in blood glucose levels for three participants (S1, JT2, J3)
however one participant, K4, experienced an increase in RBG levels despite having
the lowest baseline RBG result.

There was a surge in mean RBG levels only once, in treatment 3.

Spearman’s test for correlation suggests statistical significance between RBG levels
and reflexology intervention in three of the treatments, however due to the small
39
sample size significance cannot be assumed and further investigation with a larger
sample is recommended. Therefore, what other factors could account for this?

Only two treatments observed a RBG change greater than in the control session.
This may cast doubt on causality, ie that the decrease in blood glucose readings
during the study was caused by reflexology. However, as there was only one control
session this does not provide a strong case. It does however, heed caution and
suggest that no conclusion re. cause and effect can be drawn without further
research.

Mean MYMOP Wellbeing scores indicate a perceived decline in general quality of
life, as do mean ADDQoL General Quality of Life scores.

3 retired participants experienced either no change (K4), or a decline in diabetesspecific quality of life (JT2, J3), whilst the participant in fulltime work experienced an
improvement in diabetes-specific quality of life (S1).

Some life-areas that at baseline were most negatively impacted by diabetes
improved at follow-up, eg ‘need to depend on others’ and other life-areas were
reported as more impacted at follow-up for participants despite not previously being
of concern, ie ‘close personal relationships’ and ‘feelings about the future’.
These points of interest are considered in the discussion that follows:
Psychosocial factors
Lifestyle
It is well-accepted that blood glucose increases are caused by consumption of sugary or
sugar-forming foods, hence diabetic individuals are advised to monitor their intake of
carbohydrates and sugar. Research by Hlebowicz et al (2009) identifies that the time
taken for digestions to process affects the time blood glucose takes to decline after meals,
40
as it changes depending on what is consumed. This is due to the macronutrients in the
food item and its digestibility. Blood glucose levels rise following food consumption and, for
example, with food high in fibre, the glucose may remain in the bloodstream for a longer
period of time.
For consistency, and to try and mitigate against fluctuations in levels, blood glucose
readings were taken at the same time of day (Campbell??) However treatments being
scheduled at a consistent time there were instances when the same participant
experienced a blood sugar level increase following reflexology one week, and other weeks
levels decreased. This may have been impacted by their most recent meal, and by the time
taken for the digestive process. An example would be participant J3 who generally had a
very healthy diet, high in fibre, but ate a wide variety of foods which may have different
responses in the digestive system and, hence, cause a different glucose response.
Hlebowicz et al (2009) notes that with a dysfunctional glucose regulatory system this may
result in greater increases of processing time in diabetics.
Another variable that can impact blood glucose levels is stress. Stress hormones such as
cortisol have been shown to increase glucose levels in the blood. It was interesting that the
participant who had the lowest baseline blood glucose reading was the only to experience
an increase in levels at the end of study. Qualitative data from the follow-up interview
highlights that this participant experienced a highly stressful period due to a family situation
just after the first intervention. She advised that she had had “a very stressful time over the
time that I have been having the studies. My daughter has been going through a move so I
have taken up the role of head babysitter and through it all it has been very very stressful”.
It is possible therefore that stress may have further impaired her glycaemic control and
potentially affected her eating habits, although she did not mention any negative change in
41
eating habits. As well as experiencing a stressful time the interview also uncovered some
behavioural change which may have affected this participant’s results: “I had no-one
moving and no stress and I had just had my reading at the doctors and they revealed I was
well in the range. I was being good with my diet and that was how it was at that time”
Psychological
This confessional statement provides an indication that the baseline blood glucose reading
may have been artificially low, as the participant attended her medical check the previous
week. Some studies suggest that behaviour change can occur when visiting for medical
appointments, This participant is keen to ensure that the doctor does not prescribe
glycaemic control medication This is highly likely to have affected the baseline result in this
participant.
Some individuals find that as they become more knowledgeable about their condition and
are more aware of what is affecting their glucose levels they feel empowered and more in
control. This can then translate into better glycaemic control (Dellagaso). This may be true
of participant JT2, who had an extremely high reading in treatment 1 and advised that she
had consumed treacle on crumpets for her breakfast. Her post-test reading was
dramatically lower and she was astonished. The following week her reading dropped again,
and she started to feel positive about her results. As she became more positive, her
confidence in her ability to control her blood glucose levels increased and subsequently her
eating habits appeared to change, although she did not seem aware of it.
Another possibility is that some of the improvements in blood glucose readings were as a
result of the Hawthorne effect. Researchers found that behaviours or performance can
improve when an individual is aware that they are being monitored. Whilst glycaemic
control may improve some studies suggest that tight glycaemic control can have a
detrimental effect on perceived quality of life.
42
Quality of Life
The quality of life ratings in this study support this view, as a small decline was reported in
the disease-specific questionnaire, ADDQoL. This result was confirmed also in the
MYMOP Wellbeing rating, which also suffered a decrease. Triangulation of data collection
can increase reliability (Leedy, 2011). The generic MYMOP assessment can account for
other non-diabetes heath concerns. Shim et al (2012) suggests that health concerns other
than DMT2, such as pain, or mental health can influence quality of life in individuals with a
less severe diabetic, and those who do not have secondary diabetic complications. The
findings of this study support the view that other health concerns impact participants’
perceptions of their health. As participants are able to manage their condition without
medication they are considered to have a milder case. However there is also a decline in
the mean diabetes-specific result, which suggests that the impact of their condition became
more negative through the study. The findings confirm those of (Shim et al, 2012) in that
‘freedom to eat as I wish’ was the main diabetic-specific quality of life concern.
The three retired participants had managed their condition without too much thought for
many years, and had come to accept the limitations of the condition. However what
became apparent was that they started to question their ability to do more than they had in
the past. As blood glucose changed two started to experience what they perceived to be a
lessening of their diabetic symptoms and whilst seeing this as a positive development they
felt they were experiencing the life of a non-diabetic, which raised their expectations about
what was possible. The full-time worker, S1, however had previously been concerned
about the impact of diabetic symptoms on her employment attendance, which reflected in
her ADDQoL rating, but as she perceived her to be improving during the study this became
less of a concern, and was reflecting in her improved ADDQoL score. This suggests that
the quality of life of individuals with different circumstances are affected in different ways by
43
DMT2. As DMT2 is becoming more widespread in a wider range of ages treatment should
be tailored to the needs of the individual rather than by one approach.
Reflexology
One of the results that stands out most relating to the blood glucose readings is the surge
in blood glucose levels in treatment three. This is reasonably common in reflexology and
considered by reflexologists to be a symptom of dysfunctional or impaired functioning body
systems adjusting back to a state of homeostasis. This is described by reflexologists as a
healing crisis (Gunnarsdottir & Jonsdottir, 2010). In their study they found that women
experienced a temporary worsening of symptoms early on in the course of treatments
followed by symptoms improving, and in fact becoming better than they had been before
the downturn. This appears to describe the events of this study in relation to blood glucose
levels, as, mean blood glucose readings did continue an improving, reducing trend
following the potential healing crisis.
Treatment and mechanism of action
An improvement in symptoms with reflexology is thought to occur as a result of a the
treatment strengthening the immune function (Marquart 2007), which may clarify the
possible role of reflexology in the case of participant S1 who identified that a rash on her lip
almost disappeared during treatment, but had been there for many months prior with no
improvement. General physiology suggests that reduced function in the parasympathetic
system inhibits healing, therefore the body heals more effectively when vagal activity is
increased, which Hughes et al (2011) suggest is stimulated by reflexology. This may be a
suitable explanation of the mechanism of action relating to some of the participants
experience, eg by increasing vagal activity and hence insulin secretion thereby potentially
reducing insulin sensitivity does this offer a possible explanation of the instances where J3
44
perceived that she did not suffer the usual diabetic symptoms that she had been prone to
when missing meals, ie wobbliness?
Hughes et al (2011) conclude that a treatment of longer than twenty minutes is required,
which would support the whole-body approach working across a variety of reflexes. One of
the benefits of reflexology is that when carrying out a whole-body treatment the therapist
can tailor the treatment specifically to the needs and reactions of each individual client
(Gunnarsdottir & Jonsdottir 2010) and therefore may be explain the improvement in
different health symptoms for different clients, as seen in the results of this study. This
treatment approach can be at odds with some experimental research methods as it does
not allow for efficacy of reflexology to be proved, as it does not prove that any specific
reflex points are responsible for any change, and also may be at risk of encouraging a
placebo effect, or allowing external factors to influence outcomes (Jones et al, 2013). This
is a view that Dieppe et al (2013) agree on, noting that by tailoring a treatment to the
individuals needs reflexologists are inviting placebo effect into any study. Given the number
of body systems implicated in DMT2 it would not be considered appropriate to carry out a
treatment without excluding reflex points for those areas known to contribute to or
exacerbate diabetes.
Another possible issue when investigating the efficacy of reflexology is that there is virtually
no way to blind the therapist (Hughes et al, 2011) ,or even a non-therapist, as they will
require treatment details in order to undertake the treatment, leaving any such explorations
open to accusations of therapist bias, with suggestions that a therapist may influence the
participant to perceive a positive result. Conversely it is possible that the participant will
unconsciously or consciously wish for a positive outcome to please the therapist, or
because they have enjoy the treatments (Warren et al, 2012) and find them a pleasant
45
experience and therefore wish the study to be seen as successful. Some studies show that
in relation to diabetes a positive relationship with the therapist can influence adherence in
diabetics (Garcia-Perez et al, 2013), which may therefore lead to positive behaviour
changes such as eating habits, which in turn may result in positive results of treatment.
Limitations
As the discussion suggests this study has some limitations. Controlling for external
variables in a quasi-experimental design can be challenging (Robson, 2011), the
researcher has endeavoured to address issues on control for external variables, but alas
there are many complicating factors that may affect diabetes, which ideally require a much
more robust, structured experimental environment to have some chance of addressing
external factors effectively.
The inclusion of a control no-treatment session in this study offered some insight into how
blood glucose may react in a different situation, and alleviated over-optimism in
interpretation of results, which may have been perceived as a positive indicator of
reflexology efficacy had this not taken place. However, the control was not far reaching
enough as it only occurred once and therefore it is difficult to tell if this was a one-off effect,
or if the same decrease in blood glucose levels would happen more than once.
No significance can be assumed in the study due to the small sample size, and a lack of
randomisation in the sampling (Fox et al) and diversity in participants recruited mean that
results cannot be generalised.
46
Future Research
As a worldwide health-concern that is on the increase, and with little other research
currently available relating to the efficacy of reflexology for diabetes mellitus type 2, there is
plenty of scope for future research. Research involving a larger sample size and more
representative recruitment is recommended to allow results to be generalised. A vital
component for any future research is to take a belt and braces approach to controlling for
external variables, to improve the chances that clear conclusions can be drawn from
findings.
As a chronic degenerative condition longitudinal studies are suggested to allow any
potential long-term benefits to be realised. As diabetes is a complex condition that affects a
wide and diverse population with differing treatment requirements, a number of studies
narrowly-focussed and tailored to specific patient groups may be advantageous, to better
understand treatment requirements, efficacy of reflexology in each circumstance and
expand client-choice for the ongoing management of the condition.
Conclusion
In conclusion, this study suggests that, although some positive change was observed in
reduction of blood glucose levels, no conclusion on efficacy of reflexology can be drawn,
due to methodological limitations, detailed above, lack of significance of results and
uncontrolled, external, confounding variables.
Results suggest that reflexology may not improve health-related quality of life in this client
group. The use of a mixed methods approach has proved invaluable in mitigating against
what Robson (2011) refers to as “inappropriate certainly in conclusions”.
It has, hopefully, made a small contribution to better understanding some of the
complexities associated with perceived quality of life in female adults with un-medicated
diabetes mellitus type 2, and in raising awareness of the challenges associated with
47
proving efficacy of reflexology in this client group. With some positive trend in blood
glucose level and positive anecdotal narrative from participants it does however warrant
further research.
48
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52
Reflexology treatment Procedure Sheet:
Notes for therapist
Marquardt Reflexology map used
Protocol = Whole-body treatment in line with the Association of Reflexologists protocol
as taught on the BSc (Hons) Complementary Healthcare (with practitioner status)
course.
Primary symptomatic zone = pancreas reflex (Marquardt yellow book)
Background symptomatic zones = use list detailed in the Glycemic Control section
Therapist Note




Therapists should start with gentle pressure and carefully pay attention to client reaction
in case of sensitivity in overly tender areas.
Do not treat the pancreas reflex point in isolation (Marquardt blue/grey p130)
Avoid over-stimulation of the pancreas reflex as this may result in drastic fluctuation of
blood glucose levels during a treatment, and increase risk of hyopglycaemic episode
(REF: Marquardt books blue/grey)
Be aware that some other reflexes overlap the pancreas, eg colon, to avoid overstimulation use gentle pressure ( Marquardt yellow).
53
Quantitative Outcome Measure Scoring
Explanation of Quantitative Outcome Measure Scoring
Random blood glucose level test readings
Results are recorded in the standard unit for measuring blood glucose level, millimoles per
litre, represented as mmol/l. (REFXX). A random blood test measures the level of blood
glucose in the blood at the time of the test.
Readings were taken one at baseline phase; one immediately before and after each
reflexology intervention, 40 minutes apart; and one before and after the control ‘no
treatment’ follow up meeting, 40 minutes apart. The higher the result the more glucose
present in the blood.
MYMOP Scoring
At the first treatment the initial MYMOP form is used. The participant identifies one or two
symptoms most concerning them and rates each one separately using a likert . Participants
also select a rating using the same scoring for Wellbeing.
(Figure 6)
MYMOP Rating Scale
As good as it could be 0 1
2
3
4
5
6 as bad as it could be
Higher scores are therefore less favourable. The mean of all scale ratings is then
calculated resulting in the MYMOP Profile Score. The wellbeing scale rating can act as a
stand-alone rating to provide a MYMOP General Wellbeing Score.
54
MYMOP is completed prior to the start of each treatment, with the MYMOP Follow-up form
used in treatments 2-6.
Audit of Diabetes –Dependant Quality of Life Questionnaire Scoring
Scoring conducted in line with ADDQoL Guidelines (Appendix x). Scoring mechanisms for
the 2 stand-alone overall assessment questions are:
Q. In general my present quality of life is: scored between -3 and 3 as follows (score in
brackets): Excellent (3), Very good (2), Good (1), Neither good nor bad (0), Bad (-1), Very
bad (-2), Extremely bad (-3)
Q. If I did not have diabetes my quality of life would be: scored between -3 and 3 as
follows: Very much better (3), much better (2), a little better (1), the same (0),
worse (-1),
Each of the 19 life-area questions are then scored on a five point scale from -3 indicating
the most negative impact in having diabetes to +1 for a positive impact of having diabetes,
where 0 indicates no impact of having diabetes. The wording of the scale changes slightly
to be relevant for each question.
Each of the 19 life area questions also includes an importance rating, scored as: Very
important (3), Important (2), Somewhat important (1), Not at all important (0).
The two scores for each life-area question are then multiplied. Total scores for each of the
19 questions are then added up to give the ADDQoL Diabetes-Specific Quality of Life
Score.
55
RESULTS S1
Random blood glucose levels before and after by treatment with trend line and
difference line
blood glucose reading mmol/l
12
0.6
0.5
0.4
0.3
0.2
0.1
0
-0.1
-0.2
-0.3
-0.4
10
8
6
4
2
0
baseline
T1
T2
T3
T4
T5
T6
increment of difference mmol/l
Blood glucose levels before, after with trendline and
difference line
CONTROL
Treatment
Before
n=1
mmol/l
After
T1
Random blood glucose
before
8.2
Random blood glucose after
8.7
Difference
0.5
Baseline blood glucose = 8.2 mmol/l
Follow-up blood glucose = 6.0 mmol/l
Difference = 2.2 mmol/l
difference
Linear (After)
T2
T3
T4
T5
T6
CONTROL
9.8
10.2
0.4
8.1
8.6
0.5
8.4
8.9
0.5
6.9
7.3
0.4
6.1
5.8
-0.3
5.9
6.0
0.1
MYMOP Results S1
56
MYMOP profile score and wellbeing score
3.5
3
Axis Title
2.5
2
1.5
1
0.5
0
T1
T2
T3
T4
T5
T6
total score
3
2.5
1.5
2.5
1.5
1.5
wellbeing
2
3
2
3
2
2
total score
wellbeing
Weekly MYMOP Rating for Lip rash
4.5
4
MYMOP Rating
3.5
3
2.5
2
1.5
1
0.5
0
T1
T2
T3
T4
T5
T6
4
2
1
2
1
1
ADDQoL Questions score and importance
57
Comparison of General QoL and General Diabetes Impact
Score Baseline and Followup
1.5
1
0.5
0
-0.5
-1
-1.5
Baseline
Followup
General QoL Score
1
1
General Diabetes Impact Score
0
-1
Q. In general my present quality of life is: Baseline, Good (1); Follow-up Good (1)
Q. If I did not have diabetes my quality of life would be: Baseline, Same (0);
Follow-up a
little better (-1)
All questions were applicable and answered, those with no bars above indicate a score of 0
indicating no impact of the condition.
58
Weighted question scores
Freedom to Drink as I wish
Freedom to Eat as I wish
Depend on Others
Living Conditions
Financial Situation
Feelings about the Future
Other people's reaction
Motivation
Self-confidence
Physical Appearance
Sex Life
Close Personal Relationship
Friendships/Social Life
Family Life
Physical Ability
Holidays
Journeys
Work Life
Leisure Activities
-7
-6
-5
-4
-3
-2
-1
0
ADDQoL Score
AFTER
BEFORE
59
RESULTS JT2
Individual Stats – JT2
BGL before and after by treatment with trend line and difference line
Blood glucose levels before and after, difference and
trendline
12
1
0.5
10
0
-0.5
8
-1
-1.5
6
-2
-2.5
4
-3
-3.5
2
-4
0
-4.5
baseline
n=1
T1
T2
T3
Before
After
mmol/l
T1
T2
T3
T4
T5
T6
CONTROL
11.3
8.6
8.2
5.5
5.8
5.9
6.9
7.5
6.8
8.9
5.7
5.9
4.9
6.2
-3.8
-1.8
0.7
0.2
0.1
-1.0
-0.7
Random blood glucose before
Random blood glucose after
Difference
T4
T5
difference
T6
CONTROL
Linear (After)
Baseline blood glucose = 7.5
Follow-up blood glucose = 6.2
Difference = -1.3
60
MYMOP JT2
MYMOP profile score and wellbeing score
6
MYMOP Rating
5
4
3
2
1
0
T1
T2
T3
T4
T5
T6
total score
4
3.5
4.5
4.5
5.3
4
wellbeing
3
3
4
4
6
4
total score
wellbeing
Weekly MYMOP Rating for Right hip pain and back pain
7
MYMOP Rating
6
5
4
3
2
1
0
T1
T2
T3
T4
T5
T6
Right Hip Pain
5
4
5
5
4
4
Back pain
0
0
0
0
6
4
Right Hip Pain
Back pain
ADDQoL
General health and general diabetes impact score
comparison baseline and followup
1.5
1
0.5
0
-0.5
-1
-1.5
-2
-2.5
Baseline
Followup
General QoL Score
0
1
General Diabetes Impact Score
-1
-2
61
Q. In general my present quality of life is: Baseline, Neither good nor bad (1); Follow-up,
Good (1)
Q. If I did not have diabetes my quality of life would be: Baseline, a little better (-1);
Follow-up much better (-2)
Weighted Diabetic Impact Question scores
Freedom to Drink as I wish
Freedom to Eat as I wish
Depend on Others
Living Conditions
Financial Situation
Feelings about the Future
Other people's reaction
Motivation
Self-confidence
Physical Appearance
Sex Life
Close Personal Relationship
Friendships/Social Life
Family Life
Physical Ability
Holidays
Journeys
Leisure Activities
-10
-9
-8
-7
-6
-5
AFTER
-4
-3
-2
-1
0
BEFORE
For this client questions relating to Work Life (baseline and follow-up), Sex Life (at
baseline) were not applicable. Any others that are blank represent a ‘0’ score.
62
RESULTS J3
Individual Stats – J3
BGL before and after by treatment with trend line and difference line
12
1
10
0.5
8
0
6
-0.5
4
-1
2
-1.5
0
-2
baseline
T1
T2
T3
T4
T5
T6
CONTROL
Treatment
Before
n=1
Random blood glucose
before
Random blood glucose after
Difference
T1
9.7
10.3
0.6
After
T2
7.2
6.4
-0.8
Increment of difference mmol/l
Bllod glucose level mmol/l
Blood Glucose level Before, After with trend and
difference lines
difference
T3
9.2
9.7
0.5
T4
T5
T6
CONTROL
6.8
5.3
-1.5
7.6
6.3
-1.3
6.0
5.2
-0.8
6.9
5.7
-1.2
Baseline blood glucose = 7.4
Follow-up blood glucose = 5.7
Difference = -1.7
63
MYMOP profile score and wellbeing score
3.5
MYMOP Rating
3
2.5
2
1.5
1
0.5
0
T1
T2
T3
T4
T5
T6
total score
3
2.5
2.5
0
0
1
wellbeing
2
2
2
0
0
2
total score
wellbeing
MYMOP Rating
Weekly MYMOP rating for Left Knee pain
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Left Knee
T1
T2
T3
T4
T5
T6
4
3
3
0
0
0
64
ADDQoL J3
General QoL and Diabeties Impact Comparison
Baseline and Follow-up
3.5
3
2.5
2
1.5
1
0.5
0
-0.5
-1
-1.5
Baseline
Followup
General QoL Score
3
2
General Diabetes Impact Score
-1
-1
Q. In general my present quality of life is: Baseline, Excellent (3); Follow-up Very good (2)
Q. If I did not have diabetes my quality of life would be: Baseline, a little better (-1);
Follow-up a little better (-1)
Weighted diabetes impact questions
Freedom to Drink as I wish
Freedom to Eat as I wish
Depend on Others
Living Conditions
Financial Situation
Feelings about the Future
Other people's reaction
Motivation
Self-confidence
Physical Appearance
Friendships/Social Life
Physical Ability
-4
-3
-2
-1
0
AFTER
1
2
3
Holidays
Journeys
Leisure
Activities
4
BEFORE
65
For this client questions relating to Work Life, Family Life, Close Personal Relationships
and Sex Life were not applicable. Any others that are blank represent a ‘0’ score.
RESULTS K4
Individual Stats – K4
BGL before and after by treatment with trend line and difference line
Blood Glucose levels before, after with trend and
difference line
14
Blood glucose level mmol/l
12
10
8
6
4
2
0
-2
baseline
T1
T2
T3
T4
T5
T6
CONTROL
-4
-6
-8
Treatment
Before
n=1
Random blood glucose
before
Random blood glucose after
Difference
After
difference
Linear (After)
T1
T2
T3
T4
T5
T6
CONTROL
7.9
7.1
-0.8
9.6
9.3
-0.3
9.6
12.0
2.4
7.6
6.2
-1.4
8.2
7.3
-0.9
6.8
7.3
0.5
8.4
7.5
-0.9
Baseline blood glucose = 5.4
Follow-up blood glucose = 7.5
Difference = 2.1
66
MYMOP Profile score and Wellbeing score
MYMOP Rating
3.5
3
2.5
2
1.5
1
0.5
0
T1
T2
T3
T4
T5
T6
total score
1
1.5
2.5
2
2
1.5
wellbeing
1
2
3
3
2
1
total score
wellbeing
Weekly MYMOP Rating for Sleep
MYMOP Rating
2.5
2
1.5
1
0.5
0
Sleep
T1
T2
T3
T4
T5
T6
1
1
2
1
2
2
67
ADDQoL
Chart Title
2.5
2
1.5
1
0.5
0
Baseline
Followup
General QoL Score
2
2
General Diabetes Impact Score
0
0
Q. In general my present quality of life is: Baseline, Very good (2); Follow-up, Very good
(2)
Q. If I did not have diabetes my quality of life would be: Baseline, the same (0);
Follow-up, the same (0)
68
Weighted diabetes impact question
Freedom to Drink as I wish
Freedom to Eat as I wish
Depend on Others
Living Conditions
Financial Situation
Feelings about the Future
Other people's reaction
Motivation
Self-confidence
Physical Appearance
Friendships/Social Life
Physical Ability
Holidays
Journeys
Leisure Activities
-10
-8
-6
-4
AFTER
-2
0
2
4
BEFORE
For this client questions relating to Work Life, Close Personal Relationships and Sex Life
were not applicable, any others that are blank represent a ‘0’ score
69
PARTICIPANT CONSENT FORM
Research Study Reference Number: 8503
Participant Study ID Number:
Title of Project: The effect of Reflexology on Blood Glucose Levels and Quality of Life in
Adults with Diabetes Mellitus type 2
Name of Researcher:
___________________________________________________________________
Participant to complete this section: Please initial each box.
I confirm that I have read and understand the information sheet for the above
study. I have had the opportunity to consider the information, ask questions
and have had these answered satisfactorily.
I understand that my participation is voluntary and that I am free to withdraw at any
time prior to the data analysis stage, ie 13th March 2017, without giving any reason.
I agree to take part in the above study
I agree to the follow-up interview being audio recorded
I agree to the use of anonymised quotes in publications
_______________________________________ ___________________
Signature of Participant
Date
_______________________________________ ___________________
Name of person taking consent
Date
____________________________________
Signature of person taking consent
* When completed, 1 copy for participant & 1 copy for researcher site file
70
Participant Information Sheet
Research Study Reference number: XXXXXX
Research Title: The effect of reflexology on blood glucose levels and quality of life in
adults with diabetes mellitus type 2
Background to study
This research study will investigate whether or not reflexology has an effect on blood
glucose levels in adults who have diabetes mellitus type 2, and if it does, what those effects
may be. It will also consider if receiving regular reflexology treatment affects quality of life.
The researcher hopes that this small study will help the people who take part to keep their
blood glucose levels within the healthy range and improve their quality of life. The
number of people with diabetes mellitus type 2 is increasing and it is hoped that if any
positive results are found from this study it would help build a case for more in depth
research to be carried out.
The study will start around the 17th January 2017 and run for 9 weeks, up to 17th March.
Taking part is entirely voluntary and you can withdraw at any time during that 9 weeks.
What is reflexology?
Reflexologists believe that all our body systems and organs each have reflex points in the
feet and hands. Usually working on the feet, therapists check the reflex points to identify
those that may not be working at their best, and use specialised techniques to bring back
balance to these reflex points.
Why have I been invited to take part?
You have been asked to take part in this study as you are aged 18-76 years and diagnosed
with diabetes mellitus type 2 over 6 months ago, which you are managing through diet
and lifestyle, without medication.
You have also let me know that you have not been diagnosed with any of the secondary
conditions commonly caused by diabetes; neuropathy, cardiovascular disease, retinopathy,
nephropathy. You have not had any recent surgery, are pregnant, or currently seeing your
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GP for any other serious condition for which reflexology may be considered a risk of
causing you harm.
What if I do not want to take part?
You do not have to join the study. Taking part is completely voluntary. We are grateful to
you and thank you for taking the time to think about it.
If you decide you would like to join but then change your mind you can withdraw,
without giving a reason, at any time up to 17th March 2017 using the contact details at the
bottom of this information sheet.
What if I would like to take part?
If you agree to join the study:
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You’ll attend a local natural health centre for a one-to-one meeting with the researcher who
will explain the aims of the study and answer any questions you have.
Need to complete and sign a consent form confirming that you are happy to take part.
A therapist, who is qualified to level 5 in Clinical Reflexology, will carry out an in-depth health
questionnaire to understand your medical history, how you manage your diabetes condition
and to have a clear understanding of your general health and lifestyle.
Be asked to take a blood glucose level reading (with the therapist present)
Complete a questionnaire about the effect that diabetes has on your life. You do not have to
answer any question that you feel uncomfortable with.
Highlight any symptom that particularly bothers you.
Agree a regular day and time to receive reflexology treatments.
Next Steps
You’ll receive 6 weekly reflexology treatments. Each treatment will last about 40 minutes
and take place in a private treatment room at Holistic House natural health centre, 71 The
Philog, Whitchurch, CF14 1DZ. Immediately before and after each treatment you’ll be
asked to take a blood glucose level reading. The therapist will ask you how you found the
previous treatment and if there are any changes to your health since. You’ll also be asked
about any other symptom/s that you mentioned in your first meeting.
One week after the last reflexology treatment you’ll be asked to come to the centre to take
your blood glucose level measurement, complete the same quality of life questionnaire and
rate the severity of any other symptom/s you’ve been monitoring. The therapist will also
ask you to talk about your experiences of reflexology during the study in a short interview
which will be recorded on an audio voice recorder.
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The therapist will type up the interview word for word, and send it to you by email or post
for you to check it is accurate. You’ll need to send it back by email or post.
How much of my time will the study take?
Week
Task
1
Health questionnaire, take measurements
2
Reflexology Treatment 1 and measurements
3
Reflexology Treatment 2 and measurements
4
Reflexology Treatment 3 and measurements
5
Reflexology Treatment 4 and measurements
6
Reflexology Treatment 5 and measurements
7
Reflexology Treatment 6 and measurements
8
Short Interview and take measurements
9
Check interview notes
Time in hours
Up to 1.5 hours
1 hour
1 hour
1 hour
1 hour
1 hour
1 hour
Up to 1.5 hours
1 hour
Total amount of time for the study = approximately 10 hours over 9 weeks
All tasks except week 9 will take place at a local natural health centre.
Do I have to bring anything with me?
You need to bring your blood glucose monitoring equipment to all appointments.
Do I have to pay for anything?
Reflexology treatments are free of charge. There is free parking in the streets around the
natural health centre. You’ll be provided with a prepaid envelope if you need to return the
interview notes to the therapist by post.
No travel or other personal expenses are covered. This is at your own cost. If you need
information on timetables and costs of buses and trains to the centre please ask!
Will everything be private and confidential?
We take your privacy very seriously. Steps have been taken to make sure that all
information is strictly confidential and that your privacy is protected, so that you cannot be
identified.
Information will be stored securely in a locked cabinet and can only be accessed by
authorised people, such as the researcher, university tutor. The consent form, which
includes your name, address and contact number, will be stored at the University site and
will not leave the premises at any time. At the end of the study we will destroy all research
information. We will only keep the consent form, which we have to keep for 10 years to
comply with University regulations.
You have the right to see any of the information that we hold about you at any time.
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Are there any benefits from taking part?
All treatments and advice as part of the study are free of charge. Many people find
reflexology enjoyable and deeply relaxing. So whether or not the reflexology has any effect
on blood glucose levels you should find it a pleasant experience.
Are there any risks?
There are no known risks to your health of receiving reflexology. You may experience
some discomfort from common mild symptoms such as increased urination, tiredness,
heightened emotions and changes in body temperature, for example, feeling cold. A
thorough health consultation is carried out at the first meeting to make sure that you are in
good enough health to receive treatments. If, at any time during the study, you or the
therapist have any concern about your health you may need to withdraw from the study.
What happens to the results of the study?
All records of measurements taken are coded so that names and personal details are
removed, so no-one taking part can be identified. The results will be used as part of a
University 3rd year student research project. We’d be happy to send you a copy of the final
research report if you’d like one.
What if I have more questions?
We welcome any questions. You can make contact through the University tutor whose
details are below. Please mention the research study reference number shown at the top of
this information sheet.
Thank you for your interest
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