This article is copyright Kunz and Kunz 2006 and originally appeared in Reflexions newsletter, Volume 27, Number 1 (March 2006). It has been reprinted with permission of Kevin Kunz, Reflexions. REFLEXOLOGY REDUCES THE REQUIREMENT & QUANTITY OF PAIN KILLERS AFTER GENERAL SURGERY Shweta choudhary Ph.D,*(Dept. of Biophysics), Dr. Guresh kumar ,Dr.Kulwant singh (Dept. of Biostatistics) All India Institute of medical science, New-Delhi . PURPOSES : To find out the efficacy of reflexology in patient with post operative pain after general surgery. METHOD : 60 patients of general surgery from The All India Institute of Medical Science have been included in this study over a period of 2002-2004 June. Patients were divided randomly into two groups. Group I: Reflexology group (foot reflexology + required quantity of standard drugs). Group II: Control group (standard quantity of standard drugs). Standard Drugs were such as NSAID(Diclofenac) + Opioids (Pethidine and Fentanyl) Pain score was measured by monitoring the strength of pain on visual analog scale (VLA). In Group I pain has been measured at the time scale of 0, 2, 6, 24 hrs, and also (0 hrs-20min) (2hrs-20min) (6 hrs -20min) (24 -20min). 20 minutes is the time interval before and after therapy. In Group II pain score has been measured only at time interval 0, 2, 6, 24 hrs. (0 hrs has been defined as the time at which patient was shifted to the recovery room) 1 RESULTS : The results show a significant decrease of requirement and quantity of drugs in Group I and also a significant decrease of pain score in Group I in comparison with Group II. CONCLUSION : The effect of foot reflexology causes a significant reduction of requirement and quantity of pain killers, Another effect is a significant reduction of pain score in Group I in comparison with Group II in post-operative patients of general surgery. 2 INTRODUCTION Reflexology is an act of applying pressure on the corresponding point of disordered organ/area of body to the feet and hands with specific thumb, finger and hand techniques without using oil, lotion or creams. The physiological changes achieved with the application of pressure are based on the neurological relationship that exists between the skin and the nervous system specifically in such a manner that a therapeutic effect can be achieved by stimulation at a distance from the area where the pressure is applied. Reflexology believes the body is reiterated, or mirrored, on the feet and hands and works within a zonal system. Reflexology was introduced in the U.S. in 1913 by William Fitzgerald (H.O.D.of E.N.T in Hertfort in U.S). The base of reflexology is the zone theory which was also given by him. Fitzgerald found that if pressure was applied to the finger, it would create an anesthetic effect on the hand, or at the shoulder right up to lower arm, ears and hands. He applied the pressure using tight bands of elastic on the middle section of each finger or with small clamps, which he placed on the tips. He was able to carry out minor surgical operations just by using this pressure technique. By exerting the pressure on a specified area of the body he learned to predict which other part of the body would be affected. While developing this work he systemized the body in to zones. He established 10 equal longitudinal zones running through the body from the top of the head to the tips of the toes. 3 Zone theory: According to the zone theory, the body is divided into ten equal zones, five on the left and five on right the side of the body and parts of the body in a particular zone are linked to one another through the energy flow. If there is congestion in any part of the body, the zone gets affected. The applied beneficial use of this theory is, that direct pressure applied to any part of the zone will stimulate the whole zone. The pressure can be applied on the face, head, arms, legs, hands, feet or any part of the zone. For treating any part of the body, we first have to visualize the location and image in which zone(s) of the body the affected part lies. For large parts, the treatment covers more than one zone depending on the size of the body part. Later Dr. Riley supported the zone theory and Dr. Riley is assistant, Eunice Ingham, made the greatest contribution. She plotted the reflex of all the body glands / organs on the feet and invented the foot map, She is also known as the mother of foot reflexology. At present Reflexology has spread all over the world due to its positive effects. A . The study of reflexology is based on anatomy and physiology of human body. The Principle of reflexology is founded on the understanding of how these nerve works and what these nerves mean to the human body . Reflexology is one of the most miraculous means of utilizing nature's own healing method for maintaining the body in people under postoperative condition and with problems that are the least familiar to us. It does not require any pills, drugs and tranquilizers. The body's vital life force is circulating along pathways and we can use it at an estimated 800 points on the body. It is not necessary to know all of these point since the hand as well as the feet center "reflex buttons" which are connected to all organ and glands, When these reflex-centers are massaged, they send a stimulating surge of new vigor to whatever part of the body they are connected to instantly and with no side effects, We are correcting the imbalance in the primary flow and thereby we helping nature to do the healing. This shows how you can use the "push button" method of pressure treatment with illustration checks and easy to follow massage techniques. Reflexology is of greatest help in diagnosis by getting signals through the corresponding reflex points. Use of reflexology has increased in medical care. Recent reports include use in the area of birth, obstetric care, gynecological services, post surgical care, intensive care unit and patient support. The International Institute of Reflexology has made it perfectly clear that it does not purport to teach medicine practice in any form. 5 Theory of reflexology: In each foot, there are more then 7200-nerve ending which have an extensive interconnection with the central nervous system. These nerve ending are part of our sensory apparatus in which they sense pain and pressure hot and cold etc. The feet are also important for perception, sensing or determining the physical position of a person Essentially Reflexology stimulates or fine-tunes this sensory apparatus and its neural pathways. Further, stress patterns in the body are also manifested on the feet. There are many theories of reflexology; some important theories have been explained here. Applied theory: The foot reflects the body response to the stresses of gravity and movement. The technique is applied according to two body images of stress adaptation, zone and areas. Reflex images are projected through out the body to routinely coordinate the activity of the body .An image of longitudinal zone is projected from the brain to the body to provide instruction about an upright ailment. zones are the reorganization that all body parts must move in the relationship of gravity Blood and nerve supply theory: When the muscles becomes tense due to some reason, they press on the arteries causing sluggishness in circulation with the result that the toxin in the blood which should normally be excreted out of the body settle down at the extremities, i.e. feet and hands. 6 At these deposits, needle shaped crystals are formed. There is large number of nerve ending in the feet and these depositions interrupt some nerve impulse and cause dysfunction in the blood circulation. Reflexologist tries by methodological pressure treatment to remove these depositions and formation of these needle shaped crystal in tissue. a cause pain when systematized pressure is applied the crystals and toxins are broken down and get released into the blood stream and removed by nature through its excretory systems. Thus on working out the pain at the reflex part, the corresponding part in the body gets relieved Energy Therapy Extra terrestrial influences affect our function by altering electromagnetic environment. All living systems consist of cells, tissue and extra cellular connecting network of tubules, water and particular matter that generate energy. Matrix has a liquid crystal structure when liquid crystal are deformed it can produce minute quantities of electricity Structural and static Electrical field cause the vibration on cell membrane i.e. the effect of the receptor chamber. This leads to a chain reaction in the whole body . Pain Postoperative pain is attributed to the cutting of pain fibers or irritation of pain nerve endings. 7 Theory of pain: Gating Theory: Specific neural path way (Gate) for specific pain fibers go to the central nervous system. Due to cutting or injury of nerve fibers, the fast conducting A delta nerve fibers go through the spinothalemic tract towards the central nervous system.the brain reads the signals and the Individual feel sharp pain, Due to touch and pressure stimulation of reflex points the slow conducting C fibers take the same path way as A delta nerve fibers, but they inhibit the pain that means the pain path way is blocked. Different types of method have been used in prevention of post-operative pain. Methods: two types of methods have been used for treatment of pain. 1-Conventional method -Different type of Pain Killers- NSAID (Diclofenac)s + Opioids ( Pethidine and Fentanyl ) 2-Non-conventional method-Acupressure, Acupuncture and Reflexology. METHOD : 60 patients were randomly divided into Group I (Reflexology group) and Group II (control group). GroupI: Refloxology group (foot reflexology+required quantityofstandard Drugs). Group II : control group (standard quantity of standard drugs). The standard pain killers is used : NSAID (Diclofenac) and opioids ( Pethidine and Fentanyl) Two types of measurements have been done in this study: 8 1-Measurement of quantity and requirement of pain killers. 2-Measurement of Pain score. Pain score has been done at 4 different points of time. In Group I at the time scale of 0 , 2, 6, 24 hrs, and at (0 hrs-20min) (2hrs-20min) (6 hrs -20min) (24 -20min). (0 hrs was defined as the time at which patient was shifted to recovery room). 20 minutes is the time before and after reflex therapy. In Group II pain score has been measured at the time scale of 0, 2 , 6 , 24 hrs. The other investigation made was the decrease of the requirement measurement of significantly decrease requirement and quantity of pain killer in Group I in comparison with Group II. Pain has been monitored on a visual analog scale: Parameters monitoring Pain score Visual analog scale has been used for measurement of pain. 0-5 = Mild pain = Moderate pain 5-10 = severe pain 9 Foot reflexology for different type of surgery & related pain specific reflex point has been used for specific surgery (or related surgical areas & effective Zonal area mainly) for 15-20 minute Reflexology Technique 1. Relaxation Technique 2. Reflex working technique: a-Thumb Working Technique- Thumb walking Dig and back up b-Finger Working Technique Finger walking Finger rotary pressure 10 RESULTS : Comparison of quantity of pain killers in group I and group II Statistical analysis was done by applying the Fischer exact test(chi square test). At 0 hrs painkillers were used in Group I by 65.5% of patients whereas in Group II 100% of the patients received painkillers (P=.001) i.e. a significant decrease of painkillers in Group I. At 2 hrs painkillers were used in Group I by 19.5% of the patients whereas in Group II 85% of the patients received painkillers (P=.001) i.e. an absolutely significant decrease of requirement of drugs in Group I. At 6 hrs painkillers were used in Group I by 75% of patients whereas in Group II by 100% of the patients received painkillers. (P=.005) i.e. a significant decrease in requirement of painkillers. At 24 hrs painkillers were used in Group I by 65.5% of the patients whereas in Group II by 100% of the Patients received painkillers. (P=.002) i.e. a significant decrease of drugs requirement in Group I. This study shows a decrease of the quantity of Pain killers in Group I to less than 50% in comparison with Group II. Comparison of pain score in Group I and l Group II Statistical analysis was done by applying the "T" test. 11 RESULTS: At 0 hr in Group (I) the Mean ± SD of the pain score is 5.25±1.646 whereas in Group II the Mean ± SD 6.393±1.397 (P=.007), i.e. a significant decrease of pain. After 2 hrs in Group I Mean ±SD is 4.906±1.201 and Group II the Mean ± SD is 4.43±1 (P=.026) ie a significant decrease of pain score (due to diminished effect of anesthesia). After 6 hrs in Group I Mean ± SD is 3.813±1.5748 and Group II the Mean ± SD is 4.43±8 (P=.009) i.e. a significant decrease of pain in Group I. After 24 hrs in Group I Mean ± SD is 2.28±.683 and group II the Mean ± SD is 3.143±.5 (P=.000), i.e. an absolutely significant decrease of pain score in reflexology Group I in comparison with control Group II. Comparison of pain score in reflexology Group I before & after reflex therapy. Statistical analysis was done by applying the "T" test. Pain score at 0 hr i.e. before therapy in Group I the Mean± SD is 5.25±1.65 and in Group II at (0hrs - 20m) i.e. after therapy the Mean ± SD is 5.28±1.42 (P=.927) i.e. a non-significant decrease of pain score in Group I after getting reflexology. After 2 hrs in Group I the Mean ± SD is 4.91±1.20 and after 20 minutes (2hrs - 20 min) the Mean ± SD is 3.91±1.20 (P=.000) i.e. an absolutely significant decrease of pain after reflex therapy At 6 hrs in Group I the Mean ± SD is 3.81±1.57 at 6 hrs 20min Mean ± SD is 3.06±1.46, i.e. a significant decrease of pain after reflexology. At 24 hrs in Group I the Mean ±SD is 2.28±0.68 at (24hrs -20 min) the Mean ± SD is 1.59±.084 (P=.000), i.e. an absolutely significant decrease of pain getting foot reflexology. 12 DISCUSSION Under most circumstances pains causes the greater amount of suffering particularly after major surgeries but in some cases nausea and vomiting may be distressing, particularly after minor surgery. It is considered that there are areas of the body that have only one or two histological types of receptors and yet they are sensitive to variety of different stimuli. The type of sensation is determined by the specific area of central nervous system to which afferent nerve fiber pass. For example if a pain nerve fiber is stimulated by heat, cold ,touch and pressure, the individual will experience only pain. GATING THEORY Specific neural path way for specific pain fibers (A delta nerve fibers) go to the through spinothalemic tract towards the central nervous system. When touch and pressure is applied on specific reflex point, It would activate slow conducting c fibers which take the same path way and inhibit the path of A delta nerve fibers and pain path way blocked. According to this theory, pain signals pass through a number of traffic "gates" as they move from the area of injury upwards through the spinal cord to the brain, like a road or a high way, these nerves can handle only a limited number of nerve signals at one time, the pain signal travel slowly. We can generate the other c 13 fibers through applying of reflexology by applying pressure on a specific reflex point. Reflexology generates compete ting stimulus of C fibers and effectively block the slow pain signals from reading the brain, blocked the pain path way. The gating theory says that pain impulse can be blocked in the spinal cord by inhibiting signals coming from touch nerve fibers due to this relieve in pain. Reflex conditioning - 1. Stimulus - information is sent from the foot to the brain 2. Evaluation - The brain analyzes the information 3. Response - after brain response to the recent information by sending instruction to the entire body about how to adapt. Transduction: It is a process by which one form of energy (the stimuli) is changed to another form of energy (electrochemical energy) of nerve impulse. The stimuli when applied to the receptor ,bring about a change potential of the plasma membrane of the nerve ending, since this process take place in the receptor, it is referred to as the receptor potential , if the receptor potential large enough wide , generate an action potentials is called impulse.Impulse conduction is simply the movement of action potentials along a nerve cell. 14 REFERENCES 1. Acute pain management: operative or medical procedure and trauma. Clinical practice guideline. Washington, DC: US D partment of Health and Human Services. Public Health Service Agency for Health Care Policy and Research, Feb 1992 2. Broekema AA, Gielen MJM, Hennis PJ. Postoperative analgesia with continuous epidural sufentanil and bupivacaine: A prospective study in 614 patients. Anesth Analg 1996; 82: 754-759. 3. Brown DL, Rone DK. 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