Quackademic medicine involving reflexology

Reflexology is quackery. It’s based on magical thinking that views every major organ in the body as somehow mappable to specific points on the soles of the feet or the palms of the hands and posits that somehow massaging these areas can have therapeutic effects on the organs in question. Claims regularly made for reflexology include that it can “detoxify” the body, increase circulation, assist in weight loss, and improve the health of organs. Other conditions for which quacks claim reflexology is efficacious include earaches, anemia, bedwetting, bronchitis, convulsions in an infant, hemorrhoids, hiccups, deafness, hair loss, emphysema, prostate trouble, heart disease, overactive thyroid gland, kidney stones, liver trouble, rectal prolapse, undescended testicles, intestinal paralysis, cataracts, and hydrocephalus. It’s amazing what something that so many miraculous therapeutic effects can be attributed to what is basically a foot and/or hand massage. I mean, I like a foot massage as much as the next person, but I don’t labor under any delusions that by paying attention to specific parts of my foot a reflexologist is treating any condition.

That’s why I was disappointed when I saw a press release and news stories based on the press release floating around the Internet, morphing and making claims, as so many press releases for quackademic studies of various “alternative therapies” do. It was from a home state school, Michigan State University, and it touted reflexology as a “complementary therapy” in cancer patients. Given that I’m a cancer doctor, I really detest studies of this type. Even though its proponents try to call it “integrative medicine,” what it is doing is “integrating” quackery and pseudoscience into science-based medicine. As my good buddy Mark Crislip put it, “If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.” Make no mistake about it. Reflexology is the cow pie to medicine’s apple pie here, and “integrating” it into cancer care does not make cancer care better.

Of course, that’s not what MSU wants you to think:

A study led by a Michigan State University researcher offers the strongest evidence yet that reflexology – a type of specialized foot massage practiced since the age of pharaohs – can help cancer patients manage their symptoms and perform daily tasks.

Funded by the National Cancer Institute and published in the latest issue of Oncology Nursing Forum, it is the first large-scale, randomized study of reflexology as a complement to standard cancer treatment, according to lead author Gwen Wyatt, a professor in the College of Nursing.

“It’s always been assumed that it’s a nice comfort measure, but to this point we really have not, in a rigorous way, documented the benefits,” Wyatt said. “This is the first step toward moving a complementary therapy from fringe care to mainstream care.”

Reflexology is based on the idea that stimulating specific points on the feet can improve the functioning of corresponding organs, glands and other parts of the body.

What it should say is that reflexology is based on a prescientific idea of how the body works, complete with vitalistic references to “energy” flowing through the body between the feet and various organs. Particularly depressing, also, is that the NCI funded this nonsense. I mean, I’d expect dubious studies like this from the National Center for Complementary and Alternative Medicine (NCCAM), but not the NCI. On the other hand, the NCI does have the Office of Cancer Complementary and Alternative Medicine (OCCAM), which not only has the most unfortunate acronym ever but also a budget that is roughly equal to that of NCCAM. So, sadly, NCCAM is not the only government entity funding quackademic medicine. I wish it were, but it’s not.

I first learned that four years ago at the AACR meeting, when I visited the NCI booth on the convention floor because I knew there was going to be a representative from OCCAM there. My confidence in the scientific rigor of the entire OCCAM enterprise was not boosted by the conversation I had there. In brief, after a brief (and neutral) conversation about what OCCAM does, I gently challenged the OCCAM representative regarding alternative medicine by pointing out that there really isn’t that much evidence for much of it and asking him if he could point me in the right direction. In particular, I asked him why one would think that a mixture of herbal medicines would do better than pharmaceuticals. He then began to pontificate about “royal herbs” and couldn’t provide a good rationale why anyone should conclude that impure mixtures of compounds would be more effective or reliable than pharmaceuticals. When he started going on about “emperor” herbs, “minister” herbs, and “assistant” herbs, I couldn’t take it anymore and looked for an opportunity to politely excuse myself.

The fruits of this sort of magical thinking can be seen in studies like the one that inspired all these press releases. I located the actual grant that was used to fund this study. It’s entitled Home-based symptom management via reflexology for advanced cancer patients, and its principal investigator is Gwen Carolyn Wyatt, who is on the faculty of MSU College of Nursing. Even worse, it’s not just an exploratory R21 grant, but it’s a full-fledged RO! grant (5 R01 CA157459). Even more than that, it has a budget of over $500,000 per year, which, subtracting indirect costs, leaves a spendable budget for the PI of around $333,000. This is serious money, more than most R01s, probably because it’s being used to run a clinical trial, Home-Based Symptom Management Via Reflexology for Breast Cancer Patients that will running for at least three more years. The first paper that resulted from this study is the topic of the MSU press release, Health-Related Quality-of-Life Outcomes: A Reflexology Trial With Patients With Advanced-Stage Breast Cancer published in the Oncology Nursing Forum journal.

The study itself is no great shakes. It’s basically a three-arm randomized study of nearly 400 patients that does not appear to be blinded. (I have to go by the abstract, given that my university doesn’t carry this particular journal.) The three arms include (1) reflexology (N=95); (2) lay foot manipulation (LFM) in which a non-reflexologist gives what is basically a foot massage (N=95); and (3) conventional care control (N=96). Subjects were interviewed for breast cancer-specific quality of life measures and other metrics related to quality of life. Notice how the results are reported:

No adverse events were reported. A longitudinal comparison revealed significant improvements in physical functioning for the reflexology group compared to the control group (p = 0.04). Severity of dyspnea was reduced in the reflexology group compared to the control group (p < 0.01) and the LFM group (p = 0.02). No differences were found on breast cancer-specific HRQOL, depressive symptomatology, state anxiety, pain, and nausea.

Notice something? There’s no difference in all the primary measures that the investigators were planning to look at before the study, save one, dyspnea (shortness of breath). What this means, who knows? It stands out as being different from all the other resoundingly negative results. In fact, as this excellent editorial about this study from my alma mater’s newspaper points out, what has been left out of many reports of this study are these very important results. These included no significant differences in health-related quality of life, symptoms of depression or anxiety, pain or nausea relief. Moreover, just as we see with studies of acupuncture that include a sham acupuncture control, the group of women who received a regular foot massage showed a significant improvement in fatigue relief that wasn’t matched by the reflexology group. There’s no physiological reason why “sham reflexology” should result in improved fatigue relief, while “real” reflexology can reduce dyspnea. More likely, what we’re seeing is the sorts of random noise that we see in clinical trials. Moreover, these are all subjective results; I didn’t see any evidence that the researchers did objective lung function, which would be necessary to determine whether there really was a physiological effect, rather than dueling placebo effects between the “sham reflexology” and reflexology.

To be fair, it’s actually not true that these sorts of results weren’t mentioned, at least in the MSU press release:

They found that those in the reflexology group experienced significantly less shortness of breath, a common symptom in breast cancer patients. Perhaps as a result of their improved breathing, they also were better able to perform daily tasks such as climbing a flight of stairs, getting dressed or going grocery shopping.

Wyatt said she was surprised to find that reflexology’s effects appeared to be primarily physical, not psychological.

“We didn’t get the change we might have expected with the emotional symptoms like anxiety and depression,” she said. “The most significant changes were documented with the physical symptoms.”

Also unexpected was the reduced fatigue reported by those who received the “placebo” foot massage, particularly since the reflexology group did not show similarly significant improvement. Wyatt is now investigating whether a friend or family member can successfully deliver reflexology after being trained by certified reflexologists to perform the nine specific steps used in the study.

Reflexology did not appear to reduce pain or nausea, but Wyatt said that could be because the drugs for combating those symptoms are generally quite effective, so the women may not have reported them to begin with.

As they say, it’s not what’s mentioned and what isn’t mentioned. It’s the spin. Considerable verbiage (for a press release) is spent on describing the finding of less shortness of breath in the reflexology group, along with an explanation that claims that because of this less dyspnea subjects were able to do more. Again, what we’re looking at are all basically subjective symptoms. So there’s a lot of room for placebo effects, particularly given that the abstract mentions nothing about blinding, although it would be necessary for me to read the entire abstract to figure out if they really blinded at least the subjects. Normally if a study is double blind, it’s at least mentioned in the abstract because it’s a very important piece of information that speaks to the rigor of the trial; so I’d be shocked if this study were more than single blind. Even if this study is blinded, there’s also the issue of how good the blinding was and whether the patients guessed which group they were in. Methodological details like this are why in general I don’t like to blog about abstracts. I like to have the full paper in hand because without it I can sometimes be burned. However, before writing this I had appealed to everyone I knew for a copy of this article, and no one came through. The article annoyed me enough; so I took that risk.

My minor travails aside, when the investigators are forced to acknowledge that reflexology didn’t help pain or nausea, notice how they do a lot of handwaving to excuse this failure. Modern drugs are effective; so the women in the study didn’t have much of a problem with nausea and pain. If that’s the case, then why bother with reflexology? More likely, reflexology was, as basic science would predict, utterly useless for these indications. The authors just don’t want to admit it.

Yes, it’s your tax dollars at work, and there’s a fair amount of cash your government has still to spend on this study. But it’s all OK, because this is totally ancient, man! Wyatt tells us so:

Although health researchers only recently have begun studying reflexology in a scientifically rigorous way, it’s widely practiced in many parts of the world and dates back thousands of years.

“Reflexology comes out of the Chinese tradition and out of Egypt,” Wyatt said. “In fact, it’s shown in hieroglyphics. It’s been around for a very long time.”

If you look at the evidence that reflexology dates back to ancient Egypt, you will find it thin gruel indeed, a couple of hieroglyphics inscriptions and a passage written by Aulus Cornelius Celsus seem to be about it for historical evidence before 1913, when William H. Fitzgerald, M.D. and Dr. Edwin Bowers introduced it into the U.S.

As I said before, reflexology is quackery. There’s no good evidence that it’s of any use for any disease or condition. Wyatt’s study certainly doesn’t break that losing streak. None of this means that a foot massage might not be worthwhile. Certainly it can feel very good and help a person relax. Unfortunately, reflexologists have delusions of grandeur and think that they can use a foot massage to heal disease.

And your government is spending a half a million dollars a year for a few years in order to study this question.