REFLEXOLOGY RESEARCH – HAND REFLEXOLOGY

NOTE: RESEARCH STUDIES EVALUATING “HAND MASSAGE” AND “HAND ACUPRESSURE” HAVE BEEN INCLUDED. WITHOUT A DEFINITION OF HAND MASSAGE OR HAND ACUPRESSURE IT IS HARD TO DISTINGUISH THEM FROM REFLEXOLOGY. IF THEY ARE QUALITATIVELY DIFFERENT TO REFLEXOLOGY APPLIED TO THE HANDS, THEN THE RESULTS PROVIDE AN INTERESTING CONSIDERATION IN DETERMINING WHAT THE CONTRIBUTING FACTORS TO THE EFFECTIVENESS OF HAND MASSAGE, HAND ACUPRESSURE AND HAND REFLEXOLOGY ARE. IT WOULD BE VALUABLE TO SEE RESEARCH THAT PROVIDES A COMPARISON THAT EFFECTIVELY EVALUATES THE BENEFITS OF ALL THREE.

NOTICE THAT THE 1996 RESEARCH STUDY USES “HAND MASSAGE” IN ITS TITLE, BUT, IN ITS DESCRIPTION OF TECHNIQUE IT PRESENTS ” PRESSING BACK AND FORTH OR RUBBING A TINY CIRCLE AROUND THE REFLEX OR ACUPOINT.” THE STUDY WAS PRESENTED AT THE 1996 Reflexology Symposium Report, Beijing: China Reflexology Association.

2023

ANXIETY, PAIN, FATIGUE, HAND REFLEXOLOGY, CORONARY ANGIOGRAPHY

Effect of hand reflexology in ameliorating anxiety, pain, and fatigue among patients undergoing coronary angiography. By Eman Abdeen Ali 1, Wafaa Hassan Ali Awad 1, Mahmoud Abdelwahab Khedr 2, Emad Abd El Gawad Ali Rabie 1. Pub. by BMC Complement Med Ther. 2023 Nov 24;23(1):425. PMID: 38001461 PMCID: PMC10668458 DOI: 10.1186/s12906-023-04256-6.

The current study findings showed that hand reflexology is a simple, non-invasive nursing intervention that is effective and useful for managing pain, fatigue, and anxiety in patients undergoing coronary angiography as it resulted in a significant reduction in the severity of pain, fatigue, and anxiety after coronary angiography in the study group compared to the control group.

PAIN, ANXIETY, CORONARY ARTERY BYPASS GRAFT, SURGERY, HAND MASSAGE

The Effect of Hand Reflexology Massage on Pain and Anxiety After Coronary Artery Bypass Graft Surgery: A Double-Blind, Randomized, Placebo-Controlled Trial. By Gizem Göktuna, Necibe Dağcan, Gülşah Gürol Arslan. Pub. by J Cardiovasc Nurs. 2023 Aug 7. Online ahead of print. PMID: 37548394 DOI: 10.1097/JCN.0000000000001033

We found that hand reflexology massage was effective in reducing pain and anxiety in patients during the immediate postoperative period after CABG.

PAIN, FEAR, PEDIATRIC ICU, MUSIC THERAPY, HAND MASSAGE

Impact of music therapy and hand massage in the pediatric intensive care unit on pain, fear and stress: Randomized controlled trial. By Dilek Küçük Alemdar, Azime Bulut, Gamze Yilmaz. Pub by J Pediatr Nurs. 2023 Jul-Aug;71:95-103. Epub 2023 May 23. PMID: 37230011 DOI: 10.1016/j.pedn.2023.05.007

It was determined that hand massage and music therapy were more effective than standard care at reducing pain and fear levels during blood drawing among 12-18-year-old adolescents in the PICU.

PAIN, FATIGUE, RHEUMATOID ARTHRITIS, HAND MASSAGE, REIKI.

The effects of Reiki and hand massage on pain and fatigue in patients with rheumatoid arthritis. By Kevser SevgiÜnal Aslan, Funda Çetinkaya. Pub. by Explore (NY) 2023 Mar-Apr;19(2):251-255. PMID: 35752581 DOI: 10.1016/j.explore.2022.06.006

The mean pain score and the fatigue severity of patients decreased after Reiki and hand massage interventions and the difference was found to be statistically significant (p < 0.05).

RADIO FREQUENCY ABLATION (HEAT DESTRUCTION OF NERVE TISSUE), POSITIONING, HAND MASSAGE.

An intervention study of a combined intervention of positioning and hand massage in patients undergoing radiofrequency catheter ablation. By Yun Kyeong Lee, Mihae Im, Haeryun Cho. Pub. by Nurs Open. 2023 Mar;10(3):1404-1414. PMID: 36161778 PMCID: PMC9912443 DOI: 10.1002/nop2.1390.

The control group had low back pain, and the physical, psychological and environmental discomfort scores increased over time, whereas the experimental group showed low back pain, and the physical, psychological and environmental discomfort scores were statistically significantly decreased.

2022

JOINT PAIN, FATIGUE, SLEEP DEPRIVATION, RHEUMATOID ARTHRITIS, HAND REFLEXOLOGY

Effect Of Hand Reflexology Massage On Pain, Fatigue And Sleep Deprivation In Patients Suffering From Rheumatoid Arthritis. By Sunil Kumar Sharma , Gurjar N. R. (2022). Pub. by Journal of Pharmaceutical Negative Results, 4633–4636. https://doi.org/10.47750/pnr.2022.13.S08.599

The study result findings revealed that there was significant reduction in joint pain, fatigue and sleep deprivation after administration of hand reflexology( p=0.005). Hand reflexology can be considered an effective intervention in reducing level of pain, fatigue and sleep deprivation among rheumatoid arthritis patients.

RESPIRATORY DISTRESS SYNDROME, FOOT AND HAND REFLEXOLOGY, PREMATURE INFANTS

Comparison of the Effect of Foot and Palm Reflexology Massage on Respiratory Distress Syndrome in Premature Infants under Noninvasive Ventilation. By Aysan Miralizadeh, Akram Peyman, Neda Jamali Soltani, Tahereh Ashktorab. Pub. by Complement Med Res. 2022;29(2):100-108. PMID: 34818220 DOI: 10.1159/000517982

The reflexology massage method, especially palm reflexology massage, contributes to the mitigation of respiratory distress in preterm infants subjected to noninvasive ventilation. Hence, this low-cost and efficient intervention program can be recommended as a complementary method for preterm infants with respiratory distress.

2021

RESPIRATORY DISTRESS, PRETERM INFANTS, VENTILATION, HAND REFLEXOLOGY

Comparison of the Effect of Foot and Palm Reflexology Massage on Respiratory Distress Syndrome in Premature Infants under Noninvasive Ventilation. By Aysan Miralizadeh, Akram Peyman, Neda Jamali Soltani, Tahereh Ashktorab. Complement Med Res. 2021 Oct 29; 1-9. PMID: 34818220 DOI: 10.1159/000517982

ANXIETY, HAND MASSAGE, PREOPERATIVE PATIENTS

Benefits of hand massage on anxiety in preoperative outpatient: A quasi-experimental study with pre- and post-tests. By Zhihong Li, Brent Bauer, Marie Aaberg, Sarah Pool, Kimberly Van Rooy, Darrell Schroeder, Robyn Finney. Explore (NY).Sep-Oct 2021; 17(5):410-416. PMID: 32919894 DOI: 10.1016/j.explore.2020.08.016.

After receiving a 15-minute non-therapeutic hand massage, patients experienced reduced anxiety levels and increased satisfaction. It was also found that it is feasible to add a 15-minute non-therapeutic hand massage to the routine of a same-day surgical station.

PAIN, ANXIETY, VITAL SIGNS, VENIPUNCTURE PROCEDURE (TAKING BLOOD SAMPLE), HAND MASSAGE

Effect of Hand Massage on Pain, Anxiety, and Vital Signs in Patients Before Venipuncture Procedure: A Randomized Controlled Trial. By Saadet Erzincanli, Kadriye Sayin Kasar. Pain Manag Nurs. 2021 Jun; 22(3):356-360. PMID: 33472757 DOI: 10.1016/j.pmn.2020.12.005

Hand massage was found to be a simple, non-pharmacologic, inexpensive, and independent nursing practice that could be used to reduce anxiety and positively affect vital signs in patients before venipuncture procedure.

2020

ADHD, CHILDREN, HAND REFLEXOLOGY

Research of Hand Reflexology Stimulation in Children with ADHD. By LAVRINČÍK, Jan and Kristina TOMÁNKOVÁ. Moscow, Russia, Proceedings of the 9th International Conference on Cognitive - Social, and Behavioural Sciences (icCSBs 2020), p. 143-152, 10 pp. 2021. Pub. by European Proceedings of Educational Sciences.

The pilot research carried out showed improvement in some individuals after 90 days of targeted pressure exercises in solving a set of practical tasks. The improvement depended on the extent, form of ADHD, type of task, task time, and other factors and became the basis for further and more extensive study. The study suggests that a higher rate of targeted practical exercises or other appropriate activities may lead to improved fine and gross motoric skills in selected individuals with ADHD.

PAIN, FATIGUE, HAND REFLEXOLOGY, CORONARY ANGIOGRAPHY

"The Effect of Hand Reflexology Massage on Pain and Fatigue in Patients after Coronary Angiography: A Randomized Controlled Clinical Trial". By Nahid Rejeh, Seyed Davood Tadrisi, Shahrooz Yazdani, Kiarash Saatchi, Mojtaba Vaismoradi Pub. by Nursing Research and Practice, vol. 2020, Article ID 8386167, 8 pages, 2020. https://doi.org/10.1155/2020/8386167

Statistically significant differences were observed in pain and fatigue scores between the groups after the intervention (P=0.001). The intervention had medium to large effects on the patients’ pain and fatigue. Hand reflexology as a nonpharmacological and safe technique can be used by nurses along with other pharmacologic interventions in order to reduce patients’ suffering related to invasive procedures.

PAIN, ANXIETY, HAND MASSAGE, LIVER TRANSPLANT PATIENTS

Effect of hand massage on pain and anxiety in patients after liver transplantation: A randomised controlled trial. By Bilsev Demir, Serdar Saritas. Complement Ther Clin Pract. 2020 May; 39:101152. PMID: 32379634 DOI: 10.1016/j.ctcp.2020.101152.

The hand massage applied to liver transplant patients positively affected and decreased the severity of pain, and anxiety levels.

ANXIETY, VITAL SIGNS, COMFORT, HAND MASSAGE, CATARACT SURGERY

The Effect of Hand Massage Before Cataract Surgery on Patient Anxiety and Comfort: A Randomized Controlled Study. By Ayşe Uyar Çavdar, Emel Yılmaz, Hakan Baydur. J Perianesth Nurs. 2020 Feb; 35(1):54-59. PMID: 31551136 DOI: 10.1016/j.jopan.2019.06.012

Hand massage reduced the anxiety of patients, positively affected their vital signs, and increased their comfort.

2019

ANXIETY, VITAL SIGNS, CORONARY ARTERY DISEASES, ACUPRESSURE, HAND REFLEXOLOGY, WOMEN

Comparison of the Effects of Hand Reflexology versus Acupressure on Anxiety and Vital Signs in Female Patients with Coronary Artery Diseases. By Zohre Rahmani Vasokolaei, Nahid Rejeh, Majideh Heravi-Karimooi, Seyed Davood Tadrisi, Kiarash Saatchi, Zahra Poshtchaman, Christina Sieloff, Mojtaba Vaismoradi. Healthcare (Basel). 2019 Feb 11; 7(1):26. PMID: 30754687 PMCID: PMC6473738 DOI: 10.3390/healthcare7010026

The effects of hand reflexology and acupressure immediately and half an hour later on the reduction of anxiety and vital signs were equal (p < 0.05). Implementation of hand reflexology and acupressure can have positive effects on anxiety and vital signs in patients with coronary artery diseases. They can reduce patients' anxiety with an equal effectiveness.

2018

PAIN, PULSE, DISCOMFORT, RESPIRATION, HAND MASSAGE, TRANSRADIAL PERCUTANEOUS CORONARY INTERVENTION

The Effects of Hand Massage in Patients Who Underwent Transradial Percutaneous Coronary Intervention. [Article in Ko]. By Eun Sil Shin, Myung Hee Kim. J Korean Acad Nurs. 2018 Aug; 48(4):465-474 PMID: 30206197 DOI: 10.4040/jkan.2018.48.4.465.

Significant differences were observed between the 2 groups in the pain score, discomfort score, pulse, and respiration rate. Hand massage can be a helpful nursing intervention for transradial percutaneous coronary intervention by reducing pain and discomfort to a considerable degree.

CHRONIC HAND PAIN, HAND REFLEXOLOGY

The Effects of Hand Reflexology on Chronic Hand Pain - A Case Study. By Annalisa Derryberry, LMT Certified Hand & Foot Reflexologist. Pub. by the Academy of Ancient Reflexology. Jan. 2018. www.AcademyofAncientReflexology.com

Nine days after the last session was completed, the subject reported still having some aches and pains in her hands and wrists, but overall, she feels her energy levels are very good and her hands feel stronger after having received reflexology sessions. She reports not having any of the nettle tea (which she used to have at least daily) since the beginning of the study sessions nine weeks ago. Two weeks later, she gave a final update, saying her hands had been “amazingly fine through this cold weather...my writing has changed due to how I hold pens and pencils, and I have more control when I draw too.”

2017

ANXIETY, CORONARY ANGIOGRAM, HAND REFLEXOLOGY

Effect of short-term hand reflexology on anxiety in patients before coronary angiography: A randomized placebo controlled trial. By Fatemeh Heidari, Nahid Rejeh,Majideh Heravi-Karimooi, Seyed Davood Tadrisi, Mojtaba Vaismoradi. European Journal of Integrative Medicine. Volume 16, December 2017, Pages 1-7. https://doi.org/10.1016/j.eujim.2017.09.010

Hand reflexology alleviated anxiety without any adverse effects on patients before coronary angiography. Therefore, it can be recommended as a non-pharmacological nursing intervention along with other methods to relieve patients’ anxiety. However, future studies with a larger sample size is needed to further examine the efficacy of the hand reflexology intervention on patients’ psychological aspects.

FATIGUE, ANXIETY, STRESS, RELAXATION, HAND MASSAGE, CHEMOTHERAPY OUTPATIENTS

Hand Massage for Cancer Patients Undergoing Chemotherapy as Outpatients: A Pilot Study. By Susanne M Cutshall, Saswati Mahapatra, Rebecca S Hynes, Kimberly M Van Rooy, Sherry A Looker, Aditya Ghosh, Cathy D Schleck, Brent A Bauer, Dietlind L Wahner-Roedler. Explore (NY). Nov-Dec 2017; 13(6):393-399. PMID: 29097109 DOI: 10.1016/j.explore.2017.06.007

Significant improvement after hand massage was indicated by VAS scores for fatigue, anxiety, muscular discomfort, nervousness, stress, happiness, energy, relaxation, calmness, and emotional well-being. All patients indicated that they would recommend hand massage to other patients, and 37 were interested in receiving it during their next chemotherapy treatment.

ANXIETY, HAND REFLEXOLOGY, ANGIOGRAPHY

The effect of hand reflexology on anxiety in patients undergoing coronary angiography: A single-blind randomized controlled trial. By MaryamMobini-Bidgoli, MohsenTaghadosi, HamidrezaGilasi, AlirezaFarokhian. Complementary Therapies in Clinical Practice. Volume 27, May 2017, Pages 31-36.

Hand reflexology could effectively decrease anxiety in coronary angiography patients.

2015

ANXIETY, PAIN, SATISFACTION, HAND REFLEXOLOGY, MINIMALLY INVASIVE SURGERY

The impact of hand reflexology on pain, anxiety and satisfaction during minimally invasive surgery under local anaesthetic: A randomised controlled trial. By Briony F. Hudson, Jade Davidson, Mark S. Whiteley. Pub. by International Journal of Nursing Studies, Volume 52, Issue 12, 2015, Pages 1789-1797, ISSN 0020-7489, https://doi.org/10.1016/j.ijnurstu.2015.07.009.

Intra-operative hand reflexology is a useful adjunct to local anaesthetic varicose vein surgery, with participants in the reflexology group reporting significantly lower intra-operative anxiety and shorter pain duration than participants receiving treatment as usual.

LOWER EXTREMITY LYMPHEDEMA, HAND REFLEXOLOGY

Hand Reflexology’s Effects on Lower Extremity Lymphedema -A Case Study. By Danielle Gilmore. Florida-licensed massage therapist MA78447 Certified Hand & Foot Reflexologist. Pub. by the Academy of Ancient Reflexology.

Hand reflexology did help my subject with symptoms from lymphedema in the lower extremities and helped her to engage more in the activities of her daily life. Although one case study is not enough research to claim that all people suffering with lymphedema would benefit from reflexology, further study would seem warranted.

2014

MOTOR SKILLS, BRAIN INJURY, HAND REFLEXOLOGY

The Effects of Hand Reflexology on Functional Fine Motor Skills in Adults With Brain Injury. By John Guinta, Certified Reflexologist and Licensed Massage Therapist, Ken Cook, Certified Reflexologist and Licensed Massage Therapist, Christy Ruggiero, Occupational Therapist and Certified Reflexologist. Pub. by the Academy of Ancient Reflexology.

This study examined the effects of 12 sessions (one per week) of hand reflexology on functional fine motor skills with six subjects that were post formal rehabilitation program. Findings suggest that in addition to hand reflexology being enjoyable and relaxing to receive (as reported by 6/6 participants) it has the potential to improve functional fine motor skills and proprioceptive feedback (as demonstrated by 4/6 participants). Further research is needed using randomized controlled trials to better determine statistical significance of improvements noted and to evaluate therapeutic value of reflexology with adults with brain injury, and pairing occupational therapy with reflexology therapy in the treatment of adults with brain injury.

2012

PAIN, EDEMA, ANXIETY, HAND REFLEXOLOGY

The Effects of Hand Reflexology and Hydrotherapy on De Quervain's Tenosynovitis - A Case Study. By Terri Bishop-Brahen, RN, LMT, certified reflexologist, certified lymphatic drainage therapist. Pub. by the Academy of Ancient Reflexology. www.academyofancientreflexology.com

This particular subject responded well to hand reflexology. Reflexology is a complementary bodywork method producing an improvement in the inflammatory symptoms of de Quervain’s tenosynovitis. Reflexology supported the subject while decreasing and discontinuing prescription medications used for the inflammation and anxiety. Improvement in the physical, emotional and mental status of the subject while reestablishing her career gives credence to the effectiveness of reflexology. A future study may be considered for larger numbers of subjects experiencing progressive symptoms of inflammation.

PAIN, ANXIETY, SATISFACTION, HAND REFLEXOLOGY, MINIMALLY INVASIVE SURGERY.

The impact of hand reflexology on pain, anxiety and satisfaction during minimally invasive surgery under local anaesthetic: A randomised controlled trial. By Briony F. Hudson, Jade Davidson, Mark S. Whiteley. Pub by International Journal of Nursing Studies. Volume 52, Issue 12, December 2015, Pages 1789-1797.

2011

NICOTINE WITHDRAWAL, HAND REFLEXOLOGY

Effect of Hand Reflexology on Nicotine Withdrawal Symptoms. By Sirirat Kanokururote, Sunida Preechawong. https://api.semanticscholar.org/CorpusID:58756154 2011

Hand reflexology in addition to the smoking cessation program can better relieve nicotine withdrawal symptoms than smoking cessation program alone.

2010

AUTONOMIC NERVOUS SYSTEM ACTIVITY, STRESS, QI HAND REFLEXOLOGY

Effects of Qi Hand Reflexology on Autonomic Nervous System Activity and Physical Resistance to Stress in Inpatients. By Oh S.Y., Park O.S., Woo M.Y. Pub. by J. Korean Acad Fundam Nurs. 2010 Nov;17(4):531-538.

The results indicated that application of Qi hand reflexology for patients in the hospital is effective in regulating the autonomic nervous system activation. Implication of finding should be useful for future research.

MENOPAUSAL SYMPTOMS, SERUM HORMONES, WOMEN, KORYO HAND THERAPY

Effects of Koryo hand therapy on serum hormones and menopausal symptoms in Korean women. By Hye Sook Shin. Pub. by J Transcult Nurs. . 2010 Apr;21(2):134-42. PMID: 20220033 DOI: 10.1177/1043659609357638.

Koyo hand therapy is effective in alleviating certain menopausal symptoms and affects the serum level of FSH and LH as shown by physiological evidence and participants' self-reported symptoms. Further studies are necessary to examine the effects of KHT through more objective data.

2006

HAND ACUPRESSURE, MOXIBUSTION, PAIN, WOMEN

The Effectiveness of Hand Acupressure and Moxibustion in Decreasing Pain and ‘Coldness’ in Korean Women Who Have Had a Hysterectomy; a Pilot Study. By Shin, KR., Kwak, SA., Lee, JB., Yi, HR., Appl Nurs Res. 2006 Feb; 19(1):22-30.

Hand acupressure and hand moxibustion was found to be effective in reducing pain and coldness in Korea women who have had a hysterectomy.

2004

FATIGUE, WOMEN, HAND REFLEXOLOGY

The Effects of Self-Administered Hand Reflexology on Fatigue in Student Nurses in Clinical Practice. By Oh SY., Lim NY., J Korean Acad Fundam Nurs. 2004 Dec; Oh S.Y., Lim NY., 11(3):256-264.

Self-Administering hand reflexology was not found to be an effective method for relieving fatigue in students nurses clinical practice. Final research is needed to identify the physiological effects.

ANXIETY, PAIN, BLOOD PRESSURE, PULSE, HAND MASSAGE, SURGICAL PATIENTS

Effects of hand massage and hand holding on the anxiety in patients with local infiltration anesthesia. [Article in Ko]. By Hyun-Jung Oh, Jeong-Sook Park. Taehan Kanho Hakhoe Chi. 2004 Oct; 34(6):924-33. PMID: 15613828 DOI: 10.4040/jkan.2004.34.6.924.

The hand massage group and hand holding group were more effective than the control group in reducing anxiety, VAS (pain) score, systolic blood pressure and pulse rate.

FATIGUE, ANXIETY, EMOTIONAL STATE, CANCER, HAND REFLEXOLOGY

Effects of Hand Reflexology on Fatigue and Emotional State in Cancer Patients Receiving Radiotherapy. By Kim Myung Ae, Kim Su Jung, Kim Su Jin, Kim Yang Ji, (Keimyung University College of Nursing, Korea) Article 8 issue of Science nursing commandment No. 1, 2004. pp. 39- 47.

The degree of fatigue, anxiety, and mood state in the experimental group were significantly lower than that of the control group. The systolic blood pressure and pulse rate in the experimental group were lower than that of the control group, but diastolic blood pressure in the experimental group were not significantly lower than that of the control group.

ANXIETY, PULSE RATE, BLOOD PRESSURE, NAUSEA, VOMITING, CHILDREN, LEUKEMIA. CHEMOTHERAPY, HAND MASSAGE

E ffect of Hand Massage on Nausea, Vomiting and Anxiety of Childhood Acute Lymphocytic Leukemia with High Dose Chemotherapy. By Ji-Eun Han, Master, RN, Young-Im Moon, PhD, and Ho-Ran Park, PhD. Keimyung University College of Nursing, Catholic University of Korea, Seoul, South Korea. 2004

In conclusion, hand massage could be effective in decreasing nausea, vomiting, state anxiety, pulse rate and blood pressure of acute leukemia children receiving high dose chemotherapy.

2002

END STAGE RENAL DISEASE, HAND REFLEXOLOGY

The Effects of Hand Reflexology on Saeng-Chi and Immunity in ESRD Patients. J Korean Acad. Fundam Nurs.2002 Aug; 9(2):213-225, Korean.

Hand reflexology is found to be an effective mind-body nursing intervention for enhancing Saeng-chi responses and affecting some of the immune responses. However, further study is needed.

2001

HAND MASSAGE, PSYCHOLOGICAL & PHYSIOLOGICAL ANXIETY, CATARACT SURGERY

Effects of hand massage on anxiety in cataract surgery using local anesthesia. By M S Kim, K S Cho, H Woo, J H Kim. J Cataract Refract Surg. 2001 Jun; 27(6):884-90. PMID: 11408136 DOI: 10.1016/s0886-3350(00)00730-6

The findings indicate that hand massage decreases the psychological and physiological anxiety levels in patients having cataract surgery under local anesthesia.

1996

CERVICAL SPONDYLOSIS, TUI-NA, HAND REFLEXOLOGY

The Clinical Observation on the Treatment for 83 Cases with Cervical Spondylosis by Hand Massage Combined with Tui-Na. By Xu, Z., 1996 China. Reflexology Symposium Report, Beijing: China Reflexology Association, pages 110-114.

Hand reflexology and hand reflexology combined with tui-na were found to be effective for the relief of cervical spondylosis. Hand reflexology combined with tui-na was most effective.