RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA
PERFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION

1.

NAME OF THE
CANDIDATE AND
ADDRESS

Ms. Jessy Varghese

M. Sc. Nursing (Medical Surgical nursing)
Anuradha College of Nursing
Bangalore

2.

NAME OF THE
INSTITUTION

3.

COURSE OF STUDY AND 1st Year M. Sc. Nursing

SUBJECT

4.

Anuradha College of Nursing

Bangalore

DATE OF ADMISSION

Medical Surgical Nursing

01-05-2012

TO COURSE
5.

TITLE OF THE TOPIC

A STUDY TO ASSESS THE

EFFECTIVENESS OF FOOT
REFLEXOLOGY ON PERFORMANCE OF
DEEP BREATHING AND COUGHING
EXERCISES IN PATIENTS AFTER
STERNOTOMY IN SELECTED HOSPITALS
IN BANGALORE.

6.

BRIEF RESUME OF THE INTENDED WORK

6.1

INTRODUCTION.

Pain is an unpleasant and highly personal experience that may be impercible to others,
while consuming all parts of the persons life. Pain presents both physiologic and
psychologic dangers to health and recovery. Post-operative pain is caused by the
interaction of number of physiologic and psychologic factors. Despite the availability
of analgesic drugs and pain relieving techniques, pain remains a common problem
and a significant fear for the patient in post operative period 1
Reflex massage is used as a useful treatment method in China, Egypt and India for the
hundreds of years. Reflexology, or zone therapy, is an alternative medicine involving
the physical act of applying pressure to the feet, hands, or ears with specific thumb,
finger, and hand techniques without the use of oil or lotion. Dr Fitz Jerald introduced
some parts of body such as ear, nose and throat as treatment points for the first time in
early 1900 in south of America. According to this, the energy is following through
vertical pathways all over the body from foot to head. So, pressure on a reflex point
can effect on the whole body such as glands, bones and muscles. One of the proposed
theories is that there are canals in the body, which the life power or the vital energy
follows through them from feet to whole organs of the body and any barrier in this
flow would finally cause disease4.
In recent years, use of treatment methods of the alternative medicine such as massage
is increased in medical units.5The soft tissue touching used in the treatment massage,
would cause pain decrease and ease increase in patients and would consequently
increase patients adjustment power against occurred conditions 6
Nowadays, the relationship between heart disease and mental situation is proved.
Because of this, use of the alternative medicine for these people causes health
promotion and comfort increase that is very effective on treatment procedure 7.
Coronary diseases are the most common heart disease which in spite of recent
effective medical methods of treatment, many patients may require sternotomy for
vessel graft. Coronary artery bypass graft (CABG) is an effective method for decrease

or removal of cardiac angina.7 Chest pain in sternum is one of the most common
complications after CABG. The pain after sternotomy is probably because of the
nervous fibers cut in scar and is described as a vague pain around surgery area and in
the cut area. Pain can last for 3 months as a chronic pain that starts in first hours after
surgery and would get better usually with narcotic medications until 48 hours after the
surgery. The pain causes activation of the nervous system and then the cardiovascular
system and the created cycle would increase cardiovascular performance. The heart
rate and the blood pressure increase, increases myocardium demand for oxygen and
this would hinder the recovery procedure after surgery.
The pain also affects the activity rate of patients and increases the surgery
complications. Because of this, the effective pain control would lead to decrease of
cardio-pulmonary complications after open-heart surgery. Massage is one of the old
techniques used in pain treatment and has been considered in recent studies very
much. Anderson studied massage effect on shoulder and neck pain in patients after
CABG in year 2007. Findings of this study demonstrated the massage positive effect
on pain relief of patients.7Gunnarsdottir has recommended foot massage on pain relief
of CABG patients. Reflex massage is a simple and none invasive method that can be
taken into account as a part of nursing care in intensive units. 7 Because of this, an
interventional study was performed with the goal of evaluating the effect of foot
reflex massage on chest pain decrease in CABG patients after surgery7

6.2

NEED FOR THE STUDY

The International Association for the Study of Pain defines pain as an unpleasant
sensory and emotional experience associated with actual or potential tissue damage,
or described in terms of such damage. Post operative pain can be defined as pain
resulted from surgical intervention. Pain is generally protective, it warns of tissue
damage and prompt treatment, but post operatively it can hold up recovery. Factors
that affect post operative pain consist of the previous experience, surgical
intervention, intra operative pain management, site and size of incision and extent of
surgical trauma.9
The basic pain mechanism consists of mainly four processes such as transduction,
transmission, perception and modulation. Surgical tissue damage causes release of
substances such as bradykinin, arachidonic acid, histamine, 5-hydroxytriptamine,

substance P and prostaglandins. These chemicals stimulate peripheral pain receptors

which transmit the pain impulses. This pain impulse is transmitted to spinal cord
through neuronal fibers. From there sensory information is carried through the
spinothalamic tract and spinonueclear tract to the thalamus and the reticular activating
system. Neurons from the thalamus project to cerebral cortex for the conscious
perception of pain. (Krik.R.M, W.T. Ribbans, 2004).When pain stimulus reaches the
brain stem and thalamus naturally it stimulate the release of endorphins and
enkephalins,which may inhibit pain transmission at spinal cord.10
Reflexology is a bodywork modality in the field of Complementary and Alternative
Medicine (CAM). Reflexology is the act of applying pressure on specific areas of
hands and feet that correspond to particular organs and glands of the body using
specific thumb, finger and hand techniques. Reflexology therapies are classified in to
three types: ear reflexology, hand reflexology and foot reflexology. The basic concept
of foot reflexology promotes homeostasis. Foot reflexology improves blood
circulation, lymphatic circulation and also motivates relaxation; good sleep and
wound healing.11

6.3

REVIEW OF LITERATURE

Review of literature is a critical summary of research on a topic of interest generally

prepared to put a research problem in paper content to identify gaps and weakness on
previous studies to justify a new investigation.
The review of literature for the present study has been divided into the following
sections

Studies on the effect of foot reflex massage on sternotomy pain

Studies on the effect of foot reflex massage on pain

Studies on the effect of foot reflex massage on sternotomy pain

A study was performed to investigate the effect of foot reflex massage on sternotomy
pain of patients after coronary artery bypass graft surgery. In a quasi-experimental
study, 90 patients were randomly divided into three groups of case, control and
placebo. The reflexology group received a 10-minute right foot massage in desired
location twice a day with 6 hours intervals for 2 consecutive days. The placebo group
undertook a 10-minute left foot massage and the control group received no
intervention. Only at mentioned times, the amount of pain was measured by McGill
visual scale. The mean of pain intensity before and after intervention had significant
difference in three groups (p<0.001). Average of pain intensity in the case group was
6.4(2.1) before intervention and 3.4(5.1) after intervention. The mean of pain
intensity in control group before and after intervention was respectively 5.1(1.7) and
5(1.9). Independent T-test showed a significant reduction in intensity of postoperative pain between case and control groups (p<0.001). Foot reflex massage
appears to be a useful method for reducing sternotomy pain in patients after coronary
artery bypass graft surgery.14
Nationwide research study undertaken in Denmark reported that, reflexology
treatment has a positive effect on patients suffering from migraine and tension
headaches. The study was done at the Department of Social Pharmacy, The Royal
Danish School of Pharmacy with the help of five reflexology associations. 220

patients were participated in the study. Reflexology was performed by 78 fully trained
reflexologist. Among the patients who took part in the study, ninety percent reported
that they had already started to take the prescribed medication one month before the
study and, out of them, 36 percent had experienced ill effects from the medicines.
Eighty one percent of the prescribed medicine in the acetylsalicylic acid and
paracetamol group was taken at least twice a week and 72% of the stronger medicines
were taken at least once a fortnight which point out that the greater part of the patients
were suffering from moderate to severe symptoms. After three months of reflexology
treatments, eighty one percent of patients confirmed that reflexology helped them in
reducing their symptoms. Nineteen percent of the patients re-ported that they had
been able to completely stop the medications they had been taking before the study.15
A study was carried out to examine the effect of foot reflexology on sternotomy pain
of patients undergone CABG at Iran University of Medical Sciences (2007). This was
a quasi-experimental study, 90 patients were randomly divided into three groups of
case, control and placebo. The reflexology group received a 10-minute right foot
massage in desired location, two times a day with 6 hours interval for 2 successive
days. The placebo group received a 10-minute left foot massage and the control group
received no intervention. Pain was assessed using visual analogue scale. Outcome
showed that the mean of pain intensity before and after intervention in three groups
had a significant difference. In the case group average pain intensity before the
intervention was 6.4(2.1) and after the intervention was 3.4(5.1). In control group
the mean of pain intensity before and after intervention was respectively 5.1(1.7) and
5(1.9). Independent t-test showed a significant reduction in intensity of postoperative
pain between case and control groups.16
A randomised control trial was done to assess the effect of foot reflexology on pain
and physiological parameters after caesarean section in patients referring to Alzahra
educational center in Iran. Sixty two women were randomly divided into two groups
of case and control. The reflexology group received a 30-minute foot massage in two
sessions, with 24-hours interval. Data gathering tool included a demographic form,
step-visual analogue scale, pain score and physiological parameters form, and
chronometer. Result showed there was no demographical difference between two
groups and they were matched completely. In case group, severity of pain after first
stage of foot reflexology was lower than control group. The severity of pain after

second stage was significantly reduced in case group in comparison with control
group. After first stage of foot reflexology in case group, systolic blood pressure
decreased and after second stage it increased, but average of pain intensity showed no
significant difference assumed with control group. The mean pulse rate, after both
first and second stage, decreased significantly, but there was no significant difference
between groups. Diastolic blood pressure and respiratory rate did not vary between
case and control groups. Study concluded that foot reflexology appears to be a useful
method for reducing pain in post operative patients.17
Studies on the effect of foot reflex massage on pain
Foot reflexology in post operative pain reduction: A study was conducted at AIIMS,
New Delhi (20022004) to find out the efficiency of reflexology in postoperative pain
management. Sixty patients were divided randomly into Reflexology group (foot
reflexology and required quantity of standard drugs) and Control group (standard
quantity of standard drugs alone).Standard drugs included are NSAID (Diclofenac)
and Opioids (Pethidine and Fentanyl).Pain score was measured by using a visual
analog scale of 0 - 10. Pain was measured at the time scale of 0, 2, 6, 24 hours. 0
hours is the time which patient was shifted to recovery room. The results showed a
considerable decrease in pain scores and decrease in the requirement and quantity of
drugs among reflexology group compared to control group.18
A study was at Division of Science and Design, University of Canberra, Australia on
the use of foot massage as a nursing intervention in patients admitted with cancer. 87
patients were participated in the study and each one received a 5-minute reflexology
foot massage per foot. The study reported that the reflexology has a significant and
immediate effect on the pain, nausea, and relaxation, when it was measured with a
visual analog scale.19
A study was conducted at the Hospital of Beijing College of Languages to assess the
effect of reflexology treatment on acute lower back pain. Twenty patients between the
ages of 35 and 55, suffering from lower back strain was participated in the study. Ten
reflexology therapies were delivered to each patient. All patients reported that the
treatment had effectively reduced their pain. 5 of them obtained complete relief after
one treatment, 10 patients obtained relief after 3 to 4 treatments and 5 patients got

complete relief only after 5 to 7 treatments. No analgesics or other medications were

used all over the course of treatments.20
A study was conducted to assess the effectiveness of foot reflexology on pain and
anxiety in patients admitted with breast and lung cancer. It was a quasi-experimental,
cross over study done at medical and oncology units of a 314-bed hospital in the
South-Eastern United States. Twenty-three in-patients with breast or lung cancer were
taken for the study. The bulk of the samples were receiving regularly scheduled
opioids and adjuvant medications. Procedures included a foot reflexology to both feet
for 30 minutes during intervention condition and with at least a two-day break during
control condition for each patient. No changes were made in patients usual schedule
or medications. Following the foot reflexology intervention, patients with breast and
lung cancer experienced a significant reduction in anxiety and pain.21
A study was conducted to assess the effectiveness of foot reflexology as a pain killer
in China (1998). Reflexology was done to 60 individuals between ages 1 to 73 to
reduce the pain resulted from toothache, headache, sore throat, stiff neck, shoulder
pain,old wound, breast pain, chest & rib pain, dysmenorrhoea, abdominal pain , wrist
and leg pain and joint pain in limbs. Reflexology sessions lasted for 20 minutes to 40
minutes. Following one session 18 of the 60 were healed. 11 were nurse back to
health following 2 or 3 sessions, 22 were effectively treated after 2 or 3 sessions.
Reflexology was not effective for 9 cases after 1 to 3 sessions.22
A study was conducted to look into the efficacy of foot reflex therapy as adjuvant
treatment modality in reducing pain and anxiety in postsurgical patients with gastric
and hepatocellular cancer at Taiwan (2005). It was a randomized controlled trial.
Sixty-one patients who had undergone surgery for gastric or hepatocellular carcinoma
were randomly assigned to intervention (n = 30) or control (n = 31) group. Patients in
the experimental group received 20 minutes of foot reflexotherapy in addition to the
usual pain management during 2nd, 3rd and 4th postoperative days. Patients in the
control group got usual pain management only. Outcome was measured using shortform McGill Pain Questionnaire, VAS, summary of the pain medications taken, and
the Hospital Anxiety and Depression Scale. Intervention group reported less pain and
anxiety over time when compared with the control group. The study also revealed that

the patients in the experimental group received significantly less pain medications
than the control group.23
A study was conducted to compare effects of symptom management with reflexology
on pain and frequency of pain medication taken in old age patient with prostatectomy
at Suratthanee Hospital, Thailand (2005). Quasi-experimental, pretest post test
design was used with a control groups. 40 elderly patients were selected and allocated
to experimental and control groups. The instrument used for the study consisted of
four sessions; Symptom experienced assessment, Knowledge providing, Reflexology
and evaluation phases. Data were analyzed by using descriptive statistics and t-test.
The study reported that the posttest mean score on pain of an experimental group was
significantly lower than of the pretest. The post test mean score of pain of an
experimental group was significantly lower than of a control group. The posttest mean
score of frequency pain medication taking of an experimental group was significantly
lower than of a control group.24
A study was conducted to find out the effectiveness of foot reflexology on pain level,
vital signs and satisfaction in patients with abdominal surgery by a post graduate
student of Mahidol University, Taiwan (2003). It was a quasi experimental research
with simple cross over design. Thirty patients were randomly selected to control
group and experimental group. Control group received 30 minutes of supportive
education and experimental group received 30 minutes of foot reflexology. Pain
assessment and vital signs were recorded pre, immediately after therapy and at 15
minutes and 45 minutes interval. The results showed that patient received foot
reflexology had marked reduction in pain compared to those received supportive
education. It also reported a marked effect in vital signs.25

6.4

STATEMENT OF THE PROBLEM

A study to assess the effectiveness of foot reflexology on performance of deep

breathing and coughing exercises in patients after sternotomy in selected hospitals in
Bangalore
6.5

OBJECTIVES OF THE STUDY

To determine the pre-test level of post operative pain among sternotomy patients

in control and experimental group.

To evaluate the effectiveness of foot reflexology on level of postoperative pain

among sternotomy patients.

To find the association of level of post operative pain with selected demographic
and clinical variables among experimental group

6.6

OPERATIONAL DEFINITIONS

Effectiveness: Refers to the extent to which the foot reflexology will achieve

the desired results in reducing the post operative pain.

Foot reflexology: Refers to the therapeutic method of applying pressure to the

specific area of the feet, the reflex points to relieve the pain.
Post-operative pain: Refers to the pain following sternotomy
sternotomy; incision of the sternum as an approach for a thoracotomy. The
incision may be median, through the midline, or transverse, most commonly as
an extension of an intercostal thoracotomy incision, across the sternum and up
the other side.

6.7

HYPOTHESIS:

H1: There will be significant statistical difference in the post test level of post

operative pain among experimental group and control group

H2:There will be significant statistical difference between the pre-test and post test
level of post operative pain in both experimental.

H3: There will be significant association between pre test pain level and selected
demographic variables.

6.8

ASSUMPTIONS OF THE STUDY:

Sternotomy patients may experience post operative pain.

Foot reflexology may reduce post-operative pain among sternotomy patients.

Effectiveness of foot reflexology may have some association with demographic

variables.
6.9

DELIMITATIONS:

The study is delimited only to pain level of strnotomy patients

The study is conducted only on patients who underwent sternotomy procedure.

MATERIALS AND METHODS:

7.1

RESEARCH APPROACH:

Research approach used in this study is the evaluative approach

7.2

RESEARCH DESIGN:

The research design adopted for the present study is True experimental time series
design.
7.3

SETTING:

The study will be conducted at selected hospital in Bangalore.

7.4

POPULATION:

Population consists of all patients who underwent sternotomy procedure.

7.5

SAMPLE:

Sample selected for the present study is sternotomy patients who are residing at
selected hospitals in Bangalore.
7.6

SAMPLE SIZE:

The proposed sample size for the present study is 60

7.7

SAMPLING TECHNIQUE:

The sampling technique adopted for the study is convenient sampling.

7.2.1

SAMPLING CRITERIA:

Inclusion Criteria:
1
2
3

Adult patients who underwent sternotomy procedure.

Patients who are interested to participate in the study.
Patients who are able to read and write Kannada or English

Exclusion Criteria:
1
2
3

Patients who are working at health care sector particularly in reflexology.

Patients who had previously exposed to similar experiment.
Sternotomy patients with severe post operative complications or psychiatric
disorders.

7.9

VARIABLES:

Dependent variable:
Pain level of strnotomy patients after foot reflexology intervention
Independent variable:
Information booklet regarding effective contraceptive measures
Extraneous variable
Age, Education, Occupation, Marital status, Economic status, occupation clinical
variables of sample such as previous history of caesarean section, previous history of
hospitalization, number of deliveries, pain relief methods other than medication,
number of hours post operatively
7.10

TOOLS FOR DATA COLLECTION:

Tool 1: Socio demographic data prepared by the investigator.

Tool 2: Numerical rating scale to assess the level of pain, where the score will be
interpreted in terms of no pain, mild pain, moderate pain, severe pain and worst pain.
7.11

METHOD OF DATA COLLECTION:

Data will be collected by dividing the patients into two groups, namely experimental
group and control group by simple random sampling. Pre-test level of post operative
pain will be assessed using the numerical rating scale among the samples who meet
the inclusion criteria. The experimental group will then be given foot reflexology on
the following day, after which the level of pain will be measured using the numerical
rating scale and this will be repeated for five days. While the control groups pain will
be assessed using the numerical rating scale for five days without giving foot
reflexology. The data collection period will be for one month.
7.12

METHOD OF DATA ANALYSIS:

The collected data will be analyzed by using the appropriate descriptive and
inferential statistics method
Effectiveness of foot reflexology will be tested by using One - way ANOVA F-test.
Chi-square test will be used to find the association between level of post operative
pain with selected demographic and clinical variables. `p value <0.05 is considered as
significant. Analyzed data will be presented in the form of tables, graphs and figures.

7.13

DURATION OF DATA COLLECTION

Duration of data collection will be 4 weeks.

1

PROJECTED OUTCOME:

 The study helps the investigator to attain an idea about the effectiveness of foot
reflexology.
The study will help identify the factors affecting the effectiveness of foot reflexology
in reducing the post operative sternotomy pain.
7.15

Does the study require any investigation or intervention to be conducted

on patients or other humans or animals? If so, please describe briefly.

Yes, this study requires an intervention (foot reflexology) to be conducted on patients.

7.16

Has ethical clearance been obtained from your institution?

Yes. Ethical clearance will be obtained from the institution for conducting the study.

8.

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Friday, 27 November 2009
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24. Tanyakhanok Pongpiyapibon (2005), "Effects of symptom management with

reflexology program on pain and frequency of pain medication taking in elderly
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University

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9.

SIGNATURE OF CANDIDATE

10.

REMARKS OF THE GUIDE

11.

NAME AND DESIGNATION OF

11.1

GUIDE
SIGNATURE

:
:

11.2

CO-GUIDE
SIGNATURE

:
:

11.3

HEAD OF THE DEPARTMENT

SIGNATURE

:
:

12.

REMARKS OF THE PRINCIPAL

SIGNATURE