ORIGINAL ARTICLE

The Effect of Foot Reflexive Massage on the Physiological Indexes of

Cerebrovascular Accident (CVA) patients
AZAM TALEBIPOUR1, ALIREZA VAKILIAN2, TABANDEH SADEGHI3, AHMAD REZA SAYADI4*
1
MSc Student of Surgical Nursing, School of Nursing and Midwifery, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
2
Associate Professor of Neurology, Department of Internal Medicine, School of Medicine, Non-Communicable Diseases Research Center,
Ali Ibn Abitaleb Educational and Treatment Hospital, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
3
Assistant Professor, Department of Pediatric Nursing, Nursing and Midwifery Research Center, School of Nursing and Midwifery, Rafsanjan
University of Medical Sciences, Rafsanjan, Iran
4
Assistant Professor of Psychology, Department of Psychiatric Nursing, School of Nursing and Midwifery, Social Determinants of Health
Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
*
Corresponding Author: Ahmad Reza Sayadi; Email: sayadiahmad@yahoo.com

ABSTRACT
Background: By improving blood circulation, reflexive massage relaxes muscles and stimulates the
parasympathetic nervous
Aim: To explore the effect of foot reflexive massage on physiological indicatorsofcerebrovascular accident (CVA)
patients.
Methods: This study is a clinical trial that was performed on 60 CVA patients in the neurology department of Ali
Ibn Abi Talib Hospital in Rafsanjan. The participants were selected through convenient sampling based on the
inclusion criteria and then were placed into the two control and intervention groups using random minimization
classification. The participants in the intervention group received foot reflexive massage, while the members of
the control group received a simple foot sole massage for a 15-minute session for both feet. The data were
collected using the demographic information questionnaire and the physiological index registration form
immediately before the intervention and 10 and 30 minutes after the intervention and were analyzed with SPSS18
software using independent samples t-test, chi-square test, Fisher’s exact test, and a two-way repeated-
measures ANOVA.
Results: The results showed that systolic and diastolic blood pressure and heart rate had a statistically significant
decrease in the intervention group (p <0.05). However, there was no statistically significant difference for the
participants in the control group in terms of blood pressure and heart rate. Furthermore, there was no significant
difference between the two groups in terms of temperature changes, respiratory rate, and oxygen saturation(p
<0.05).
Conclusion:Based on the findings of this study, foot reflexive massagecan be used to reduce systolic and
diastolic blood pressure and heart rate in CVA patients.
Keywords: Ischemic stroke, Reflexive Massage, Physiological Indicators

INTRODUCTION ranging from mild and transient complications such as

blurred vision to permanent paralysis or even death6.
Cerebrovascular accident (CVA) is one of the leading In order to survive and achieve long-term outcomes,
causes of disability in adults and continues to be a major the blood supply to brain tissue is important and vital.
public health problem. CVA accounts for a large proportion Therefore, when taking care of CVA patients, the blood
of nervous system disorders, and studies have predicted supply to the brain tissue should be considered as the first
that by 2020, the cerebrovascular accident will be changed priority, and even after the critical stages, continuous
from the six leading cause to the fourth leading cause of monitoring is needed. The most important symptoms of
disease burden. The disease is the second leading cause decreased blood flow to the brain are bradycardia, changes
of death in the United States, with 4.7 million outbreaks in in breathing pattern, decreased blood pressure, altered
the United States, with an estimated cost of $ 57.9 billion a level of consciousness, headache, and vomiting7. In the
year1,2. A sudden increase in CVA cases and related costs first few days after an acute ischemic stroke, a rise in
are expected in Western countries from 2010 to 20303, temperature was reported in half of the patients, indicating
resulting in severe disability4. poor prognosis. Harmful effects of the initial increase in
If the blood flow to a part of the brain is stopped, that body temperature have been attributed to an increase in
part is notable to function normally. This condition is called the body's metabolic needs, such as changes in
a cerebrovascular accident (CVA). There are generally two cerebrospinal fluid permeability8. Controlling vital signs
types of cerebrovascular accidents: ischemic stroke and provides information about the client's normal conditions.
hemorrhagic stroke. If a blood vessel is blocked by a blood Changes in vital signs can indicate changes in
clot, it can lead to an ischemic stroke, and if a blood vessel physiological functions, so monitoring hemodynamic status
ruptures in the brain and blood leaks into the brain tissue, a and physiological indicators in CVA patients is a routine
hemorrhagic stroke can occur5. An ischemic stroke can and vital practice9.
cause several neurological defects and complications There are many treatments available including
depending on the location and extent of the affected tissue, complementary medicine techniques that nurses can use to
help patients improve their health. Reflexive massage is a

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Foot Reflexive Massage

comprehensive approach and nursing intervention that vital signs of patients hospitalized in the general intensive
supports traditional care10. In recent years, the use of care unit". They selected 50 patients using convenient
reflexive massage methods in medical units has increased, sampling. The patients' physiological indicators (heart rate,
and institutions are widely using reflexive massage to treat mean arterial pressure, and blood oxygen saturation were
and help patients. Foot reflexive massage is one of the recorded for 5 minutes (once every minute) on the monitor,
treatments available in complementary medicine and then the feet were massaged for 5 minutes by the
belongs to the group of manual massage therapies and is researcher, and vital signs were recorded immediately after
one of the six most widely used methods in complementary the intervention for 5 minutes. The results of the study
and alternative medicine in Norway, Denmark, and the showed that massage is not effective on the vital signs of
United Kingdom11. Foot reflexive massage has a long patients hospitalized in the general intensive care unit 22.
history. It has existed in Egypt since about 2330 thousand Mohammadpour et al. examined the effect of reflexive
years ago and in ancient China four thousand years ago. massage on blood pressure of 68 patients with
Reflexive massage is based on the idea that each of the cerebrovascular accidents who were selected using
body's organs has a corresponding reflexive area in the convenient sampling and randomly divided into two groups.
soles of the feet, hands, and ears. The founder of foot In the intervention group, blood pressure was measured
reflexive massage, Younes Ingham, believed that and recorded by the researcher 10 minutes before the
massaging these areas using unique techniques would intervention, and the massage was performed for 30
increase the blood flow to the organs at each point in the minutes for each patient. The patients’ blood pressure was
foot. measured again immediately, 10 minutes, and 20 minutes
Complementary therapy, unlike pharmacological after the intervention. The participants in the control group
treatments, has no serious or economic complications and received no intervention. The results of the study
is simple and acceptable for the patient 12. Paying attention suggested that foot massage is effective in the vital signs of
to complementary therapies in nursing, as they can be patients with cerebrovascular accidents2. Given the
done without a doctor's prescription, provides a way for the contradictory findings of the previous studies in the
professional independence of nurses. Adding a reflexive literature, the prevalence of cerebrovascular accident, and
massage to nursing skills increases the possibility of the fact that the use of foot reflexive massage causes
comprehensive care13. Reflexive massage is massage emotional and psychological communication between the
applied in certain areas of the body that can be useful in nurse and the patient, the authors of the present study
relieving pain14 and eliminating physiological disorders as were motivated to explore the effect of foot reflexive
well as specific complaints and causes peace and massage on the physiological characteristics of CVA
relaxation in different parts of the body and one of the patients admitted to Ali Ibn Abi Talib Hospital in Rafsanjan
advantages of this massage is that it is cheap and in 2018.
comfortable and increases the family's cooperation in care
without the need for special equipment13. METHODOLOGY
Reflexive massage improves blood flow, relaxes
muscles and stimulates the parasympathetic nervous This randomized clinical trial study was conducted in 2018
system 15, and by stimulating the vagus nerve, reducing on 60 CVA patients admitted to the neurology department
cortisol and norepinephrine, and increasing serotonin can of Ali IbnAbiTalib Hospital in Rafsanjan. The patients were
be effective in improving physiological characteristics16. selected through convenient sampling based on the
However, some studies such as Ernst’s review articledo not inclusion criteria and then were placed into the two control
provide convincing evidence for the effectiveness of and intervention groups using random minimization
reflexive massage in treating medical conditions16. classification. The process for selecting the participants
Several studies have examined the effects of reflexive started after the approval of the research project by the
massage, including the effect of reflexive therapyon blood Research Council of Rafsanjan University of Medical
pressure, triglycerides, and blood sugar17, improving Sciences under the code of ethics REC.1397.020) and
anxiety in patients undergoing chemotherapy18, reducing registration in the Iranian Registry of Clinical Trials under
depression, and improving the function of the immune number IRCT2018030304038936N3. The sample size was
system 19, pain relief20, and fatigue reduction However, estimated to include 24 persons for each group based on a
these studies have presented conflicting results and some study by Mohammadpour et al. and using the following
have considered reflexive massage as effective and some formula. However, given the dropout rate, 30 persons were
as ineffective. For example, Shaban et al. conducted a considered for each group.
study entitled “Immediate effect of foot massage on the
2 σ22
(Z1−α + Z1−β ) × (σ12 + )
2 k
n1 =
∆2
n2 = k × n1 β = 0.10 → Z1−β = 1.29α=0/05 Z1−α = 1.96σ1 = 0.69
2

Where σ1 = 0.69 is the standard deviation of after the intervention for the participants in the control
temperature measured 30 minutes after the intervention for group, K = 1 is the sample size in the two groups under
the participants in the intervention group,σ2 = 0.81 is the study, and ∆ = 0.7 is the minimum difference in average
standard deviation of temperature measured 30 minutes temperature which is clinically significant.

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 Azam Talebipour, Alireza Vakilian, Tabandeh Sadeghi et al

The inclusion criteria were the willingness to sole. Then, the pressure was applied directly by the thumb
participate in the study, definitive diagnosis of on the solar plexus of each foot for 15 minutes (6 minutes
cerebrovascular accident, having the level of of pressure, 3 minutes of rest, and 6 minutes of pressure).
consciousness based on the Glasgow Coma Scale (GCS) To this end, the pressure of 3-4 kg was applied circularly
of above 7, being over 30 years old, having no cardiac on the second day (Figure 1). The participants in the
arrhythmia, having a heart rate more than 60 beats per control group were treated by simple foot massage without
minute, having a temperature above 36.5 °C, having compressing the standard points with the same conditions
systolic blood pressure above 90, having not sensitivity in and time for the intervention group. Immediately after, 10
the foot and not suffering from vascular disorders in the minutes and 30 minutes after the intervention, the
foot, lack of amputation of the lower limbs, having no participants’ temperature, heart rate, blood pressure,
wounds, infections, and skin diseases in the foot, not taking respiratory rate, and oxygen saturation of the arterial blood
medications such as nitroglycerin, dopamine, and were checked and recorded by the researcher. Finally, the
dobutamine, having no history of mental illness, no collected data were analyzed with SPSS 18 software
suffering from osteoporosis, and not having neurological through the independent samples t-test, chi-square test,
diseases. The exclusion criteria wereunwillingness to Fisher's exact test, and a two-way repeated-measures
participate in the study, not tolerating the intervention, and ANOVA at the significant level of 0.05 (p<0.05).
having acute and critical conditions during the intervention.
The data were collected using two forms1: The RESULTS
demographic information questionnaire and information
about the disease including ten questions and(2) a form for The participants in this study were 60 CVA patients (30
recording physiological indicators at different times (10 persons in the intervention group and 30 persons in the
minutes before the intervention, immediately after the control group). The average age of the participants in the
intervention, 10 minutes later, and 30 minutes after the intervention and control groups was 65.800±12.642 and
intervention). The instruments used in the study were a 68.566±13.800, respectively. There was no significant
digital thermometer (Easy life), a blood pressure monitor difference between the two groups in terms of age (p =
(Easy life Aplicado 300, Japan),a stethoscope (NMC-S-20, 0.623). Besides, the analysis of the participants’
China), and a pulse oximeter(PC-66B, China) to measure demographic data showed that the two groups did not
heart rate and the oxygen saturation of arterial blood. Also, show statistically significant differencesin terms of
the number of patient breaths was counted and recorded demographic characteristics (Table 1).
by another researcher by observing chest movements per To evaluate the time effects (changes in mean heart
minute. Before starting the intervention, the participants rate, systolic and diastolic blood pressure through repeated
were examined by a neurologist, and the necessary measurements over time), group effects (the changes in
explanations about the research project were provided to the mean scores through repeated measurements over
the patients who met the inclusion criteria, and they time) and time-group interaction (changes in mean heart
completed a consent form. Then, the researcher and a rate, systolic and diastolic blood pressure over time by
male assistant who completed reflexive massage training taking into account the effect of groups), a two-way
performed the massage intervention for the participants repeated-measures ANOVA was used. The results of the
according to their sex. It should be mentioned that the multivariate test showed that the effect of time-group
researcher had completed a reflexive massage training interaction (p<0.01) as well as the time effect was
course in Tehran under the supervision of the National statistically significant (p<0.01). Besides, the results of the
Massage Association of IRI and obtained the between-subject effect test to examine the group effect
relatedcertificate. Thephysiological indicators (heart rate, suggested statistically significant differences (p<0.01).
respiratory rate, temperature, oxygen saturation, and blood Therefore, statistical modeling was used to provide a
pressure) of the participants in the intervention group were detailed analysis of the time-effect interaction and the trend
measured and recorded 10 minutes before the start of the of changes in mean heart rate, systolic, and diastolic blood
intervention by another researcher. The validity of the pressure in different groups and times.
devices was also confirmed by receiving a calibration The results of the independent samples t-test showed
certificate, and the measures related to participants were that mean heart rate and systolic and diastolic blood
further checked and approved by two experts. pressure were not significantly different between the two
Prior to the intervention, the researcher examined the groups before the intervention (p <0.05). besides, as shown
patient's foot for skin conditions, and after performing a in (Table 2), the time to measure the mean heart rate and
general reflexive massage, specialized reflexive systolic and diastolic blood pressure has a significant effect
massagewas performed pressing the important reflexive (p<0.01). Accordingly, it can be suggested that regardless
points of the foot sole such as the solar plexus and the of group membership, there is a significant difference
points related to pituitary, spinal cord, spine, pelvis, and between the scores of the research variables ten minutes
limbs by using the thumb and forefinger. Foot reflexive before the intervention, immediately after the intervention,
massage was performed first on the left foot and then on and ten and thirty minutes after the intervention.
the right foot for 30 minutes (15 minutes for each foot). To The time-group interaction effect was also significant
do so, the participants were asked to lie on the bed in a (p <0.05), which shows that the rate of decrease in the
relaxed state and close their eyes. After massaging the mean heart rate and systolic and diastolic blood pressure in
foot, the foot heel was held with the left hand and the foot the intervention group are significantly higher than the
was dipped from the ankle by applying pressure to the foot control group. This implies the significant effect of the

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intervention on the number of heartbeats, systolic blood measurement, there is a significant difference between the
pressure, and diastolic blood pressure. The group effect is mean scores of the research variables in the intervention
also significant on the mean score of the research group and the control group (p<0.01).
variables, showing that regardless of the time of

Table 1. A comparison of the absolute and relative distribution of the participants in the two groups according to their demo graphic
characteristics
Variable Intervention Control Frequency P-value
Number % Number % Number %
Gender Male 15 48.4 16 51.6 31 100 0.796
Female 15 51.7 14 48.3 20 100
Marital status Single 2 40 3 60 5 100 0.640
Married 28 50.9 27 49.1 55 100
Education Illiterate 17 53.1 15 46.9 32 100 0.689
Primary school 7 41.2 10 58.8 17 100
Diploma 6 45.5 5 45.5 11 100
Income < 20 million Rials 24 48 26 52 50 100 0.488
20-40 million Rials 6 60 4 40 10 100
Job Farmer 5 62.5 3 37.5 8 100 0.718
Employee 6 40 9 60 15 100
Housewife 12 54.5 10 45.5 22 100
Self-employed 7 46.7 8 53.3 15 100
History of coma Yes 1 33.3 2 67.7 3 100 1
No 29 50.9 28 49.1 57 100
Type of stroke Hemorrhagic 2 40 3 60 5 100 1
Ischemic 28 50.9 27 49.1 55 100
Number of strokes None 11 44 14 56 25 100 0.420
Once 11 47.8 12 52.2 23 100
Twice 8 66.7 4 33.3 12 100
Smoking habits Yes 11 52.4 10 47.6 21 100 0.787
No 19 48.7 20 51.3 39 100

Table 2: A comparison of the mean scores (heartbeats and systolic and diastolic blood pressure) in the studied groups at diff erent times
Variabl Intervention time Intervention Control group Two-way repeated-measures ANOVA
e group
Mean ± SD Mean ± SD Sourc Sum of Mean df F Effect P-value
e of squares squares size
chang
es
Number Before the 76.67±8.69 74.77±10.57 Time 38.946 2.284 17.054 3.193 0052 0.038
of intervention
heartbe Immediately after the 76.50±8.56 74.20±10.21 Time- 54.413 2.423 22.454 4.461 0.071 0.01
ats intervention group
10 minutes after the 75.77±8.80 74.60±10.40
intervention
30 minutes after the 74.50±8.44 74.70±10.58
intervention
Systolic Before the 139.68±22.08 137.43±16.73 Time 1667.533 1.702 979.76 14.23 0.0197 0.001
blood intervention 2 8
pressur Immediately after the 135.83±21.23 136.53±17.061 Time- 946.733 1.702 556.25 8.084 0.122 0.001
e intervention group 5
10 minutes after the 129.43±20.62 136.20±17.25
intervention
30 minutes after the 128.73±19.92 135.77±13.92
intervention
Diastoli Before the 81.63±1.23 80.43±7.68 Time 958.850 1.893 506.60 34.97 0.376 < 0.0001
c blood intervention 3 9
pressur Immediately after the 80.20±9.76 79.73±7.26 Time- 342.267 1.893 180.84 12.48 0.177 < 0.0001
e intervention group 4 6
10 minutes after the 75.87±9.76 78.80±7.54
intervention
30 minutes after the 73.73±18.19 78.33±7.42
intervention

The results of the Bonferroni test showed that the Similarly, the results of the Bonferroni test suggested
changes in the number of heartbeats in ten minutes before, that the changes in diastolic blood pressure were
immediately after the intervention, and ten minutes after the significantly different for the participants in the intervention
intervention was significantly different from the number of group in all three stages except for the diastolic blood
heartbeats thirty minutes after the intervention (p <0.05). pressure ten minutes before and immediately after the
However, there was no statistically significant difference in intervention (p <0.00001). However, there was no
the number of heartbeats of the participants in the control statistically significant difference in diastolic blood pressure
group between the three stages. of the participants in the control group between three
stages.

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 Azam Talebipour, Alireza Vakilian, Tabandeh Sadeghi et al

Finally, the results of the Bonferroni test indicated that decreased heart rate, and improved oxygenation in
the changes in systolic blood pressure were significantly critically ill patients in intensive care units28.
different for the participants in the intervention group in all Valiani et al. found that foot reflexive massagefor 15-
three stages (p <0.05). In contrast, there was no 05 minutes in postpartum women resulted in a significant
statistically significant difference in systolic blood pressure difference in systolic and diastolic blood pressure29 and foot
of the participants in the control group between three reflexive massage was effective in reducing patients' blood
stages. pressure after abdominal surgery30. Another study by
Also, the results of the two-way repeated-measures Howangsuvannakor and McVicar showed that foot reflexive
ANOVA showed that the changes in temperature, massage significantly reduced systolic blood pressure in
respiratory rate, and blood oxygen saturation in the two healthy individuals but did not significantly alter their
groups were not statistically significant (P <0.05). diastolic pressure31. Won et al. also showed that foot
reflexive massage significantly reduces systolic and
diastolic blood pressure in patients undergoing
chemotherapy, which is consistent with the results of the
present study32. Padial et al. also concluded that foot
reflexive massage increases diastolic and systolic blood
pressure33. Wilkinson et al. performed foot reflexive
massagefor 20 patients with chronic obstructive pulmonary
disease in two experimental and control groups. They
concluded that foot reflexive massage had no effect on
blood pressure34. In another study Mirzaei et al. performed
foot reflexive massage for primiparas women and showed
no significant difference between control and intervention
(Figure-1) groups in terms of changes in systolic and diastolic blood
pressure35. Hatan et al. investigated the effect of foot
DISCUSSION massage and guided relaxation in patients undergoing
heart surgery and showed that foot massage has no effect
To meet the needs of patients, caregivers or even patients on any of the physiological indicators36. Similarly, a study
themselves are looking to find other treatments besides by Park et al.showed that foot reflexive massage did not
pharmacotherapy. Patients may believe in complementary have a significant effect on diastolic blood pressure, which
and alternative medicine therapies and choose them is not consistent with the results of the present study37.
because of beliefs inherited from the past. According to However, the results of a study Kaur et al. on the effects of
medical experts, if complementary medicine is not reflexive massage on physiological indicators of critically ill
scientifically proven, it should not be used as a care and patients in ICU indicated that that massage increased the
treatment strategy (24). The results of the present study patients’ diastolic blood pressure28, which is inconsistent
suggested that apart from blood pressure and heart rate, with the results of the present study. These contradictory
there was no significant difference in the number of results are probably due to differences in the research
breaths, temperature, and oxygen saturation of arterial samples, techniques, depth and strength, the area where
blood after foot reflexive massage. Khoshtrash et al. found foot reflexive massage was applied, and more importantly
that 30 minutes of foot reflexive massage in two sessions the nature and type of the disease and its different
with an interval of 24 hours in women after cesarean mechanisms in patients with different diagnoses. In the
section did not significantly affect physiological indicators present study, reflexive massage was performed in the
including blood pressure, heart rate, and respiratory rate25. solar plexus of the foot. Reflexive massage improves blood
These findings are in conflict with our results concerning flow, relaxes muscles, and stimulates the parasympathetic
blood pressure and heart rate. The difference in results is nervous system15. It also stimulates the vagus nerve,
probably due to the fact that Khoshtrash et al. did not reduces cortisol and norepinephrine, and increases
considerthe solar plexus, while the present study serotonin and thus can be effective in improving
consideredthe solar plexus massage. Moeini et al. showed physiological indicators16.
that the mean systolic and diastolic blood pressure in
patients before coronary artery bypass grafting in the CONCLUSION
experimental group had a statistically significant difference
after the use of reflexive foot massage, which was The results of the present study suggested that foot
significant between the two groups. However, heart rate reflexive massage has blood pressure lowering effects.
and respiratory rater after foot reflexive massage in the Therefore, this finding is of clinical importance in nursing
experimental group did not show a significant difference26. care because reducing blood pressure without the use of
Jones et al. also found that massaging the upper half medication is an important goal of care and can reduce the
of the sole of the left foot in healthy persons altered cardiac side effects associated with medications. Therefore, given
indicators such as heart rate, systolic anddiastole blood to the results of the present study and since the teaching of
pressure, and mean arterial pressure27. Kaur et al. showed this technique by nurses to patients and their families is
that foot reflexive massage significantly reduced systolic simple, also considering the high prevalence of
blood pressure, increased diastolic blood pressure, cerebrovascular accident, low cost of the reflexive
massage and the absence of complications or side effects

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associated with reflexive massage, the training, and 10 Abdi, Ashwandi, Khodayar, Karimpourian, Beigi M,
application of this method is recommended for medical Homayounfar. Effect of Foot Massage on Blood Pressure
staff, especially nurses. Unfortunately, massage is less and Pulse Rate of Patients Admitted to the Cardiology
Corps. Journal of Urmia Nursing and Midwifery Faculty.
popular today for a variety of reasons, including time
2016; 14 (1): 47-55.
constraints, lack of manpower, use of superior
11. Jones J, Thomson P, Lauder W, Leslie SJ. Reported
technologies, and increased complexity of care. The treatment strategies for reflexology in cardiac patients and
findings of this study could be a prelude to further research. inconsistencies in the location of the heart reflex point: an
Given that the effects of foot reflexive massage in this online survey.Complementary therapies in clinical practice.
study were controlled only up to 30 minutes after the 2012;18(3):145-50.
intervention, it is recommended that more studies be .21 .Mansouri A, Shadadi H, Poudineh-Moghadam M, Vahed
performed on the effect of foot reflexive massage in the AS, Dehghanmehr S. Evaluation of the effect of foot
long run. reflexology massage on vital signs and anxiety after blood
Acknowledgments: The authors would like to all the staff transfusions in children with thalassemia. Bali Medical
Journal (Bali Med J) 2017, 6, (3): 623-629
and patients of the Neurology Department of Hazrat Ali
13. Abdelaziz SHH, Mohammed HE. Effect of foot massage on
IbnAbitaleb Hospital in Rafsanjan who sincerely cooperated
postoperative pain and vital signs in breastcancer
in this study. we also extend our gratitude to the officials patient.Journal of Nursing Education and Practice.
and the financial support of the Research Deputy of 2014;4(8):115.
Rafsanjan University of Medical Sciences. 14. Tiran D, Chummun H. Complementary therapies to reduce
Ethics in Publication: The protocol of the effect of foot physiological stress in pregnancy. Complementary
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Research of Rafsanjan University of Medical Sciences therapy. 2004
under No. IR.RUMS.REC.1397.020 and was registered in 16 Ernst E. Is reflexology an effective intervention? Asystematic
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