EVIDENCE BASED NURSING: EFEKTIVITAS PIJAT KAKI PADA

PASIEN HIPERTENSI

KEPERAWATAN KOMPLEMENTER

oleh

Linda Fitriawati
NIM 162310101241

PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
2019
EVIDENCE BASED NURSING: EFEKTIVITAS PIJAT KAKI PADA
PASIEN HIPERTENSI

KEPERAWATAN KOMPLEMENTER

Disusun guna menyelesaikan tugas mata kuliah keperawatan

komplementer dengan dosen pembimbing Ns. Mulia Hakam, M.Kep.,
Sp.Kep.MB

oleh

Linda Fitriawati
NIM 162310101241

PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
2019
 PRAKATA

Puji syukur kehadirat Allah SWT atas segala rahmat dan hidayah-Nya
sehingga saya dapat menyelesaikan tugas mata kuliah keperawatan medikal yang
berjudul “Evidance Based Nursing : Efektifitas Relaksasi Pijat Kaki pada
Pasien Hipertensi”. Evidance based nursing ini disusun untuk memenuhi
tugas mata kuliah keperawatan medikal, dimana dalam penulisan tugas ini saya
mengucapkan terimakasih kepada :

1. Ns. Mulia Hakam, M.Kep., Sp.Kep.MB selaku dosen pengampu mata

kuliah keperawatan medikal
2. teman-teman mahasiswa Fakultas Keperawatan Universitas Jember kelas
E yang telah membantu. Kritik dan saran yang membangun sangat saya
harapkan dari pembaca demi menyempurnakan tugas ini. Semoga tugas
ini dapat bermanfaat dan menambah pengetahuan pembaca.

Jember, 22 Maret 2019

Penulis
 DAFTAR ISI

HALAMAN JUDUL ................................................................................... i

PRAKATA .................................................................................................... ii
DAFTAR ISI ................................................................................................. ii
BAB 1. PENDAHULUAN........................................................................... 5
Latar Belakang ........................................................................5
Tujuan .....................................................................................5
Manfaat Penerapan EBN ........................................................................... 6
BAB 2. METODOLOGI PENELITIAN................................................... 7
PICO (Problem, Intervention, Comparative, Outcome) ...........7
BAB 3. PROSEDUR APLIKASI ............................................................... 11
Subjek .............................................................................................. 11
Kriteria Inklusi ................................................................................ 12
Kriteria Eksklusi .......................................................................12
Prosedur Pelaksanaan EBN............................................................ 12
BAB 4. PEMBAHASAN ............................................................................. 13
BAB 5. PENUTUP ....................................................................................... 15
Kesimpulan .................................................................................... 15
Saran ............................................................................................... 15
DAFTAR PUSTAKA .................................................................................. 16
 BAB 1. PENDAHULUAN

Latar Belakang
Hipertensi dikenal juga dengan sebutan tekanan darah tinggi.
Hipertensi ini terjadi apabila peningkatan tekanan darah sistol dan diastol
secara konsisten di atas 140/90 mmHg. Hipertensi menjadi salah satu
penyakit yang sering dijumpai di Indonesia. Hipertensi dapat menyerang
berbagai kalangan di masyarakat dari tingkat sosial tinggi hingga
menengah kebawah. Selain itu, meningkatnya usia pada seseorang
beresiko untuk menderita hipertensi akan semakin besar dan karena
pengaruh usia seseorang terhadap kemunculan stres juga sering terjadi
(Marisna, 2017).
Berdasarkan data WHO pada tahun 2014 didapatkan bahwa
penyakit kardiovaskuler merupakan pembunuh nomor 1 di dunia untuk
usia diatas 45 tahun dan diperkirakan 12 juta orang meninggal tiap
tahunnya. Secara global hipertensi diperkirakan menjadi penyebab 7,5 juta
kematian, sekitar 12,8% dari total seluruh kematian. Tekanan darah tinggi
merupakan faktor risiko utama pada penyakit jantung koroner dan stroke
iskemik serta hemoragik. Tingkat tekanan darah telah terbukti positif dan
terus berhubungan dengan risiko stroke dan penyakit jantung koroner.
Selain penyakit jantung koroner dan stroke, komplikasi hipertensi
termasuk gagal jantung, penyakit pembuluh darah perifer, gangguan ginjal,
perdarahan retina dan gangguan penglihatan (WHO, 2014). Prevalensi
keseluruhan tekanan darah tinggi pada orang dewasa berusia ≥25 tahun
sekitar 40% pada tahun 2008. Prevalensi hipertensi tertinggi berada di
Afrika yaitu sebesar 46% pada pria dan wanita (WHO, 2014). Di Inggris,
34% pria dan 30% wanita menderita hipertensi (diatas 140/90 mmHg) atau
sedang mendapatkan pengobatan hipertensi. Prevalensi hipertensi di dunia
hampir satu miliar orang dan diperkirakan pada tahun 2025, jumlahnya
mencapai 1,6 miliar orang (Palmer dan William, 2007).
 Hasil dari Riskesdas (2013) Prevalensi hipertensi di Indonesia yang
di dapat melalui pengukuran pada umur ≥ 18 tahun sebesar 25,8%,
tertinggi di Bangka Belitung (30,09%), diikuti Kalimantan Selatan
(29,6%), dan Jawa Barat (29,4%). Untuk prevalensi provinsi Sulawesi
Utara berada di posisi ke 7 dari 33 provinsi yang ada di Indonesia yaitu
sebesar 27,1%. Berdasarkan Hasil Riset Kesehatan Dasar tahun 2013,
kecenderungan prevalensi hipertensi berdasarkan wawancara pada usia ≥
18 tahun menurut provinsi di Indonesia tahun 2013, Jawa Timur berada
pada urutan ke-6 (Depkes RI, 2013).
Morbiditas dan mortalitas yang terjadi pada pasien hipertensi dapat
dicegah dengan intervensi yang mempertahankan tekanan darah di bawah
140/90 mmHg. Intervesi yang dilakukan salah satunya dengan tehnik
nonfarmakologis. Tehnik nonfarmakologis yaitu intervensi dengan selain
obat-obatan, dimana salah satunya yaitu dengan teknik relaksasi.Teknik
relaksasi dapat menurunkan denyut jantung dan TPR dengan cara
menghambat respons stres saraf simpatis (Corwin, 2009). Teknik relaksasi
memiliki pengaruh yang sama dengan obat antihipertensi dalam
menurunkan tekanan darah. Prosesnya yaitu dimulai dengan membuat
otot-otot polos pembuluh darah arteri dan vena menjadi rileks bersama
dengan otot-otot lain dalam tubuh. Efek dari relaksasi otot-otot dalam
tubuh ini akan menyebabkan kadar norepinefrin dalam darah menurun
(Mills, 2012).
Berkenaan dengan penatalaksanaan hipertensi di atas, terapi
konservatif dengan terapi komplementer merupakan pilihan yang bisa
dipertimbangkan untuk meminimalkan efek samping yang ditimbulkan
dari terapi farmakologis. Dalam Peraturan Menteri Kesehatan Republik
Indonesia No. 1109 tahun 2007 menyebutkan pengobatan komplementer
merupakan pengobatan meliputi promotif, preventif, kuratif, dan
rehabilitatif yang dilakukan oleh tenaga kesehatan dengan keamanan dan
efektifitas tinggi salah satu terapi kompelementer tersebut adalah terapi
pijat refleksi. Pijat refleksi merupakan suatu metode memijat titik-titik
tertentu pada tangan dan kaki. Manfaat pijat refleksi untuk kesehatan
sudah tidak perlu diragukan lagi. Salah satu khasiatnya yang paling
populer adalah untuk mengurangi rasa sakit pada tubuh. Manfaat lainnya
adalah mencegah berbagai penyakit, meningkatkan daya tahan tubuh,
membantu mengatasi stress, meringankan gejala migrain, membantu
penyembuhan penyakit kronis, dan mengurangi ketergantungan terhadap
obat obatan. Teknik-teknik dasar yang sering dipakai dalam pijat refleksi
diantaranya: teknik merambatkan ibu jari, memutar tangan dan kaki pada
satu titik, serta teknik menekan dan menahan. Rangsangan rangsangan
berupa tekanan pada tangan dan kaki dapat memancarkan gelombang
gelombang relaksasi ke seluruh tubuh (Wahyuni, 2014).

Tujuan
Tujuan Umum
Mengetahui keefektifan dari pijat kaki pada pasien
hipertensi untuk menurunkan tingkat tekanan darah, kecemasan, dan
kualitas kesehatan.
Tujuan Khusus
1. Mendapatkan gambaran tingkat tekanan darah, kecemasan, dan
kualitas kesehatan pada pasien hipertensi.
2. Mendapatkan gambaran keefektifan pijat kaki pada tingkat tekanan
darah, kecemasan, dan kualitas kesehatan pasien hipertensi

Manfaat Evidance Based Nursing (EBN)

Manfaat bagi Penulis
Menambah pengetahuan tentang konsep pijat kaki sebagai terapi
komplementer dalam manajemen menurunkan tingkat tekanan darah,
kecemasan, dan kualitas kesehatan pada pasien hipertensi, serta
meningkatan kemampuan dalam penulisan EBN.
Manfaat bagi Institusi Pendidikan
Menambah informasi dan literatur dalam pembelajaran asuhan
keperawatan khususnya keperawatan komplementer, serta dapat digunakan
untuk bahan diskusi dalam pengabdian masyarakat.
Manfaat bagi Pelayanan Kesehatan
Menjadi bahan pertimbangan dan masukkan terhadap terapi
adjuvan pada pasien hipertensi.
 BAB 2. METODELOGI PENELITIAN

PICO (Problem, Intervention, Comparative, Outcome)

Problem
Stres dan kecemasan adalah penyebab utama hipertensi dan
kematian dari penyakit kardiovaskular. Sebagai contoh, Whitehall II
Study, sebuah studi kohort 7268 pria dan wanita Inggris, menunjukkan
bahwa persepsi stres dikaitkan dengan peningkatan risiko penyakit jantung
koroner dan menemukan bahwa mereka dengan stres yang dirasakan
memiliki risiko penyakit jantung koroner dari dua kali lipat mereka yang
tidak stres yang dirasakan. Selain itu, stres mental akut telah terbukti
memicu penyakit jantung seperti infark miokard akut dan kematian
mendadak. Menurut Walker et al., Setiap tahun 14% dari kematian di
seluruh dunia (sekitar 8 juta kematian) yang berasal gangguan mental
seperti kecemasan dan depresi. Selain itu, menurut Departemen Kesehatan
and Peraturan Tenaga Kerja, pada tahun 2014, lebih dari 60% pekerja
melaporkan merasa stres, kecemasan, dan kekhawatiran. Oleh karena itu,
penting untuk mengurangi stres mental dan kecemasan untuk
meningkatkan kualitas hidup (QOL) dan mencegah penyakit
kardiovaskular.

Intervention
Perawat akan melakukan intervensi pijat kaki dengan aromaterapi
untuk menurunkan hipertensi yang sebabkan oleh stres dan kecemasan.

Comparative
Terapi yang biasa dilakukan oleh pasien hipertensi yaitu responden

ditempatkan di sebuah sauna (Suhu kamar dan kelembaban adalah 38˚C).

Outcome
Penerapan program terapi pijat kaki aromaterapi dalam manajemen
stes dan kecemasan diharapkan dapat menurunkan tekanan darah serta
 meningkatkan kemampuan, kemauan serta keyakinan pasien dalam
melakukan perawatan diri guna mencapai fungsi hidup pasien secara
optimal.

Pertanyaan Klinis
Apakah terapi pijat kaki aromaterapi dapat membantu pasien untuk
menurunkan tingkat stress dan kecemasan pada pasien hipertensi?

Metode Penyelusuran Jurnal

Unsur PICO Analisis Kata Kunci
(Terapi)
P Complementary therapy for patient with Hypertension disease
hypertension

I Relaksasi pijat kaki aromaterapi Relaxation of foot

massage

C Terapi yang biasa dilakukan pada pasien

hipertensi di ruang terapi (sauna)
O Menurunkan stres dan kecemasan Stress, anxiety
pada pasien hipertensi

Jurnal Database yang Digunakan

Menggunakan kata kunci dan beberapa sinonimnya dari analisa

PICO, penulis memasukkannya ke dalam search engine jurnal sebagai
berikut :
a. http://search.proquest.com
b. http://search.ebscohost.com/
c. http://www.sciencedirect.com/
d. http://www.scopus.com/
e. http://www.guideline.gov/
 f. http://www.evidence.nhs.uk/
didapatkan 38 judul artikel, kemudian dipilih sebanyak 10 jurnal
relevan. Keseuaian dengan keadaan yang sebenarnya membuat penulis
memilih 2 artikel pilihan untuk kemudian memilih 1 artikel sebagai
rujukan dan sisanya sebagai artikel pendukung.

Temuan Artikel Pilihan dari Kata Kunci PICO

Jurnal Rujukan Utama Pelaksana EBN:

The Effects of Aroma Foot Massage on Blood Pressure and Anxiety in
Japanese Community-Dwelling Men and Women: A Crossover
Randomized Controlled Trial

Abstrak

Tujuan: untuk menyelidiki efek dari pijat kaki aroma pada tekanan darah,
kecemasan, dan kualitas kesehatan yang berhubungan dengan kehidupan
(QOL) pada pria yang tinggal di komunitas Jepang dan wanita
menggunakan crossover acak terkontrol.
Metode: Lima puluh tujuh peserta yang memenuhi syarat (5 laki-laki dan
52 perempuan) berusia 27-72 secara acak dibagi menjadi 2 kelompok
intervensi (kelompok A: n = 29; kelompok B: n = 28) untuk berpartisipasi
dalam pijat kaki aroma 12 kali selama 4 minggu periode intervensi.
Sistolik dan tekanan diastolik darah (SBP dan DBP, masing-masing),
detak jantung, kecemasan negara, dan kualitas hidup yang berhubungan
dengan kesehatan diukur pada baseline, 4 minggu tindak lanjut, dan 8
minggu tindak lanjut. Efek dari aroma pijat kaki intervensi pada faktor-
faktor tersebut dan proporsi peserta dengan kecemasan yang dianalisis
menggunakan model campuran efek linear untuk desain crossover
disesuaikan dengan peserta dan periode efek. Selanjutnya, hubungan
antara perubahan SBP dan kecemasan negara antara peserta dengan
kecemasan lega dinilai menggunakan model regresi linier.
Hasil : Aroma pijat kaki secara signifikan menurunkan rata-rata SBP ( p =
0,02), DBP ( p = 0,006), dan kecemasan negara ( p = 0,003) serta proporsi
peserta dengan kecemasan ( p = 0,003). Meskipun secara statistik tidak
signifikan ( p = 0,088), aroma pijat kaki juga meningkatkan skor mental
kualitas hidup yang berhubungan dengan kesehatan. Perubahan SBP
memiliki korelasi yang signifikan dan positif dengan perubahan
kecemasan negara ( p = 0,01) antara peserta dengan kecemasan lega.
Kesimpulan: Aroma pijat kaki intervensi dikelola sendiri secara
signifikan menurunkan rata-rata SBP dan DBP serta negara skor
kecemasan, dan cenderung meningkat skor QOL healthrelated mental.
Hasil penelitian menunjukkan bahwa aroma pijat kaki mungkin merupakan
cara yang mudah dan efektif untuk meningkatkan kesehatan mental dan
tekanan darah.

Jurnal Pendukung:
Effect of Nursing Interventions Using Foot Reflexology on Blood
Pressure and Quality of Life of Hypertensive Patients at Mansoura
University Hospitals: Preliminary Results

Abstrak

Tujuan: Mengetahui pengaruh refleksi kaki pada tekanan darah dan

kualitas hidup di antara pasien hipertensi.
Metode: Sebuah studi kuasi-eksperimental con- menyalurkan untuk pasien
dengan hipertensi menghadiri klinik rawat jalan Rumah Sakit Khusus
Medis di Mansoura University, Mesir, yang terdaftar dalam penelitian ini
selama enam bulan, secara acak dialokasikan ke dalam dua kelompok yang
sama (40 pada kelompok refleksi kaki (intervensi), dan 40 pada kelompok
kontrol. Dua alat yang digunakan untuk pengumpulan data: I: Demografi
dan medis jadwal wawancara. II: Kualitas Hidup Kuesioner.
Hasil: Tekanan darah sistolik menurun secara signifikan pada kelompok
intervensi dari 160.2mmHg ke 136.5mmHg dibandingkan dengan
(162.5mmHg ke 155.2mmHg) di kontrol. Ada statis- penurunan tically
signifikan dalam cara tekanan darah diastolik antara pra dan pasca
intervensi (102.0mmHg -87.5mmHg) dalam kelompok intervensi ( p <
0,05), Perubahan pada kelompok kontrol tidak terbukti signifikan secara
statistik (100.1mmHg -96.4mmHg pasca pembacaan pra dan masing-
masing, p> 0,05). Tidak ada bukti untuk perbaikan dalam Kualitas Hidup
pada kedua kelompok (pre tingkat itu 42,2, 47,1 dan pasca tingkat adalah
45,9, 47,4 dalam 2 kelompok masing-masing).
Kesimpulan: Penelitian ini didukung bahwa refleksi kaki dapat
mengurangi tingkat tekanan darah pada penderita hipertensi, tidak
mendukung bahwa refleksi kaki bisa meningkatkan kualitas hidup pada
pasien ini.

Jurnal Pembanding:

A Study to assess the effectiveness of Back massage on Anxiety level,

Heart rate and Blood pressure among Hospitalized Hypertensive patients
at selected Hospitals Tumkur
Abstrak

Tujuan: Untuk menilai efektivitas pijat punggung pada tingkat

kecemasan, detak jantung dan tekanan darah di antara pasien hipertensi
yang dirawat di rumah sakit Tumkur
Metode: Desain eksperimen semu dengan 120 pasien hipertensi, 60 untuk
kelompok eksperimen dan 60 untuk kelompok kontrol dialokasikan
melalui teknik purposive sampling.
Hasil: Hasil penelitian menunjukkan bahwa pijat punggung sangat efektif
dalam mengurangi tingkat kecemasan, mempertahankan denyut jantung
dan mengurangi dan mempertahankan tekanan darah di antara pasien
hipertensi yang dirawat di rumah sakit dalam kelompok eksperimen
daripada kelompok kontrol. Ada hubungan yang signifikan antara skor
pretest dan post test tingkat kecemasan, detak jantung dan tekanan darah
dengan usia, status pekerjaan, pendapatan tahunan keluarga, lamanya
rawat inap pasien hipertensi dan tidak ada hubungan antara jenis kelamin
dan status perkawinan.
Kesimpulan: Studi ini menyimpulkan bahwa pijat punggung efektif dalam
mengurangi tingkat kecemasan, menjaga denyut jantung, dan mengurangi
serta menjaga tekanan darah.
 BAB 3. PROSEDUR APLIKASI

Pelaksanaan EBN ini mengacu pada penelitian Eri Eguchi, Narumi Funakubo,
Kiyohide Tomooka, Tetsuya Ohira, Keiki Ogino, dan Takeshi Tanigawa (2016) :

Subjek
Pasien yang didiagnosa hipertensi dan menjalani perawatan di
klinik, rumah sakit atau rumah.

Kriteria Inklusi
Pria dan wanita berusia 20 sampai 72 yang tinggal di atau dekat
Matsuyama, Ehime Prefecture, Jepang

Kriteria Eksklusi
1. Responden yang hamil,
2. Memiliki takikardia (denyut jantung [HR] 110 denyut / menit),
bradikardia (HR 50 denyut / menit),
3. hipertensi berat (tekanan darah sistolik [SBP] 180 mmHg, diastolik
BP [DBP] 110 mmHg),
4. aritmia yang parah, atau penyakit kardiovaskular.

Prosedur Pelaksanaan EBN

1. Perawat akan melakukan intervensi pijat kaki dengan aromaterapi

untuk menurunkan hipertensi yang sebabkan oleh stres dan
kecemasan. Intervensi tersebut dilakukan dengan langkah pertama
merendam kaki responsen di dalam baskom berisi air hangat
dengan suhu 40oC selama 10 menit.
2. Kemudian responden dilakukan pijat aroma kaki selama 45 menit
dibawah pengawasan instruktur terlatih. Pertama, responden
menempatkan minyak pada tangan dan dihirup aromanya.
3. Berikutnya, perawat mengoleskan minyak untuk kaki mereka dan
memijat mereka dengan mengurut kaki dari paha hingga jari kaki
mereka. Responden juga dirangsang titik akupunktur mereka pada
tekanan-tenakan di beberapa titik. Terapi yang biasa dilakukan oleh
pasien hipertensi yaitu peserta ditempatkan di sebuah sauna selama

5 menit. (Suhu kamar dan kelembaban adalah 38˚C).

4. Kemudian responen diberikan minum 40 ml air jahe panas selama

proses tersebut. Semua peserta dilakukan prosedur ini 3 kali
seminggu selama 4 minggu (total 12 kali) selama periode
intervensi.
5. Prosedur ini dilakukan pada hari Selasa, Kamis, dan Minggu, dan
peserta yang hadir tercatat. Peserta yang tidak bisa berpartisipasi
pada hari-hari intervensi diizinkan untuk berpartisipasi pada hari-
hari lain pada minggu yang sama.
6. Minyak aroma yang digunakan dalam percobaan ini dicampur
untuk relaksasi serta kesehatan mental dan fisik oleh seorang
spesialis aromaterapi. Lavender, chamomile, cendana, ylang-ylang,
dan marjoram yang dicampur dengan jojoba (minyak pembawa)
dan diawetkan pada suhu kamar untuk digunakan.
 BAB 4. PEMBAHASAN

Hipertensi diakui sebagai penyakit yang beresiko menyebabkan

penyakit jantung, stroke, penyakit jantung koroner, penyakit ginjal, dan
demensia. Hipertensi sering disebut sebagai silent killer, hal ini terjadi
karena penyakit tersebut tidak memiliki gejala yang khas yang disadari
oleh penderitanya. Seseorang yang telah didiagnosa hipertensi maka akan
selamanya dalam kondisi hipertensi, jika faktor pencetusnya tidak
dikendalikan. Hipertensi yang tidak segera ditangani juga dapat
menyebabkan pecahnya pembuluh darah di otak yang dapat menjadi
penyebab stroke, dapat juga menyebabkan gagal ginjal, kebutaan, dan
gangguan kognitif.
Pasien hipertensi sebagian besar disebabkan oleh peningkatan stres
dan kecemasan yang diraskan oleh pasien. Stes dan kecemasan yang
berakibat hipertensi dapat diturunkan dengan terapi komplementer seperti
refleksi kaki. Teknik tekanan diterapkan pada kaki dipercaya dapat
membantu suplai saraf membuka blokir dan meningkatkan aliran darah,
yang dapat membantu tubuh untuk berfungsi pada puncaknya. Hal ini
menyatakan bahwa relaksasi dapat mengurangi stres dan ketegangan.
Dengan melakukan terapi ini dipercaya dapat membawa sekitar
vasodilatasi, tekanan darah, aliran darah meningkat dan penyediaan nutrisi
yang kaya oksigen ke sel-sel. Beberapa peneliti menyarankan bahwa 70
sampai 80% dari semua penyakit dan penyakit datang dari stres termasuk
hipertensi, migrain, sakit kepala, pilek, borok dan penyakit jantung
koroner.
Relaksasi pijat kaki sebagai pendekatan yang komprehensif dan
intervensi keperawatan yang mendukung perawatan tradisional dapat
digunakan dalam perawatan medis. Banyak penelitian telah menyelidiki
relaksasi sebagai intervensi keperawatan non-invasif dan non-farmakologis
dalam berbagai aspeknya seperti dampak pijat refleksi pada hipertensi,
mengurangi trigliserida dan gula darah, meningkatkan mual dan muntah
pada pasien kanker yang menjalani kemoterapi, mengurangi depresi dan
meningkatkan fungsi sistem kekebalan tubuh, meningkatkan rasa sakit dan
kecemasan pasien. Ada hubungan yang positif antara tingkat stres dan
kecemasan pada pasien hipertensi dengan relaksasi pijat kaki yang mampu
menurunkan tingkat tekanan darah pasien. Sehingga program relaksasi
pijat kaki efektif untuk menurunkan tekanan darah pada pasien hipertensi.
Kemudian dibangingkan dengan pijat punggung pada pasien
hipertensi juga memiliki keefektifan dalam menurunkan tekanan darah
sehingga akan lebih baik apabila pijat kaki ini dikombinasikan dengan
pijat punggung sehingga dapat meningkatkan hasil yang diinginkan.
Keefektifan kombinasi keduanya juga perpengaruh kepada pasien yang
akan diintervensi dan melihat kriteria indikasi dan kontraindikasinya.
Sehingga hasil yang dingginkan dapat diperoleh secara maksimal.
 BAB 5. PENUTUP

Kesimpulan

Hipertensi diakui sebagai penyakit yang beresiko menyebabkan

penyakit jantung, stroke, penyakit jantung koroner, penyakit ginjal, dan
demensia. Pasien hipertensi sebagian besar disebabkan oleh peningkatan
stres dan kecemasan yang diraskan oleh pasien. Stes dan kecemasan yang
berakibat hipertensi dapat diturunkan dengan terapi komplementer seperti
refleksi kaki. Relaksasi pijat kaki sebagai pendekatan yang komprehensif
dan intervensi keperawatan yang mendukung perawatan tradisional dapat
digunakan dalam perawatan medis. Relaksasi pijat kaki yang telah
diterapkan pada pasien hipertensi terbukti mampu menurunkan tekanan
darah pada pasien hipertensi sehingga dapat disimpulkan ada hubungan
yang positif antara tingkat stres dan kecemasan pada pasien hipertensi
dengan relaksasi pijat kaki yang mampu menurunkan tingkat tekanan
darah pasien. Program relaksasi pijat kaki efektif untuk menurunkan
tekanan darah pada pasien hipertensi. Lebih baik lagi apabila pijat kaki ini
dikombinasikan dengan pijat punggung.

Saran
Setelah membahas teknik relaksasi pijat kaki pada pasien dengan
hipertensi, diharapkan mahasiswa keperawatan dan petugas kesehatan
khususnya perawat dapat memahami dan memodifikasi perawatan
maupun pemberian terapi bagi pasien dengan hipertensi terutama untuk
masalah manajemen stres dan kecemasan pasien. Karena relaksasi pijat
kaki ini terbukti efektif dalam menurunkan stes dan kecemasan pada
pasien hipertensi yang berdampak penuran tekanan darah pasien, sehingga
perawat dapat menjalankan perannya sebagai mana tugas perawat.
 DAFTAR PUSTAKA

Amalina, R.N. 2018. Efektifitas Pijat Refleksi Kaki Terhadap Penurunan

Tekanan Darah Lansia Hipertensi Di Pstw Budi Luhur Yogyakarta.
Staff Dosen Akademi Keperawatan “YKY” Yogyakarta. Vol 4: 1-10

Arianto, A., Prastiwi, S., Sutriningsih, A. 2018. Pengaruh Terapi Pijat

Refleksi Telapak Kaki Terhadap Perubahan Tekanan Darah Pada
Penderita Hipertensi. Nursing News. Vol 1:3 584-594

Biswas, S., Asokan. Lenka, A., Patro, S. 2018. A comparative study to

assess the effectiveness of foot massage & back massage in reducing
blood pressure among hypertensive patients admitted in Medicine
ward attertiarycare hospital, Bhubaneswar. IOSR Journal of Nursing
and Health Science (IOSR-JNHS). Vol 7:1 01-06 e-ISSN: 2320–
1959.p- ISSN: 2320–1940 www.iosrjournals.org

Egunci, E., Funakobo, N., Tomooka, K,. Ohira, T., Ogino, K. 2016. The
Effects of Aroma Foot Massage on Blood Pressure and Anxiety in
Japanese Community-Dwelling Men and Women: A Crossover
Randomized Controlled Trial. Plos One. 10.1371: 1-13.
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Marisna, D., Budiharto, I., Sukarni. 2017. Pengaruh Terapi Pijat Refleksi
Kaki Terhadap Perubahan Tekanan Darah Pada Penderita Hipertensi
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Keperawatan, Fakultas Kedokteran, Universitas Tanjungpura. Vol
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Ramu. Gowda, Y.,K.,R., Bharati, M. 2018. A Study to assess the

effectiveness of Back massage on Anxiety level, Heart rate and
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www.iosrjournals.org

OPEN ACCESS
Citation: Eguchi E, Funakubo N, Tomooka K, Ohira
T, Ogino K, Tanigawa T (2016) The Effects of Aroma
Foot Massage on Blood Pressure and Anxiety in
Japanese Community-Dwelling Men and Women: A
Crossover Randomized Controlled Trial. PLoS ONE
11(3): e0151712. doi:10.1371/journal.pone.0151712
Editor: Yoshihiro Fukumoto, Kurume University
School of Medicine, JAPAN
Received: December 21, 2015
Accepted: March 3, 2016
Published: March 24, 2016
Copyright: © 2016 Eguchi et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.
Data Availability Statement: All of the data is
available in Open Science Framework. DOI: 10.
17605/OSF.IO/MW7X2.
Funding: Health Labour Sciences Research Grant,
Comprehensive Research on Life-Style Related
Diseases including Cardiovascular Diseases and
Diabetes Mellitus (H26-Junkankito(Seishuu)-Ippan-
008) from the Japanese Ministry of Health, Labour
and Welfare (A-MED), http://www.amed.go.jp/en/ TO.
The funders had no role in study design, data
collection and analysis, decision to publish, or
preparation of the manuscript.
PLOS ONE | DOI:10.1371/journal.pone.0151712 March 24, 2016
RESEARCH ARTICLE
The Effects of Aroma Foot Massage on Blood
Pressure and Anxiety in Japanese
Community-Dwelling Men and Women: A
Crossover Randomized Controlled Trial
Eri Eguchi1☯*, Narumi Funakubo1☯, Kiyohide Tomooka2, Tetsuya Ohira3, Keiki Ogino1,
Takeshi Tanigawa2
1 Department of Public Health, Okayama University Graduate School of Medicine, Dentistry and
Pharmaceutical Sciences, Okayama, Japan, 2 Department of Public Health, Juntendo University Graduate
School of Medicine, Tokyo, Japan, 3 Department of Epidemiology, Fukushima Medical University School of
Medicine, Fukushima, Japan
☯ These authors contributed equally to this work.
* eri_eguchi@okayama-u.ac.jp
Abstract
Objectives
The aim of this study was to investigate the effects of aroma foot massage on blood pres-
sure, anxiety, and health-related quality of life (QOL) in Japanese community-dwelling men
and women using a crossover randomized controlled trial.
Methods
Fifty-seven eligible participants (5 men and 52 women) aged 27 to 72 were randomly
divided into 2 intervention groups (group A: n = 29; group B: n = 28) to participate in aroma
foot massages 12 times during the 4-week intervention period. Systolic and diastolic blood
pressure (SBP and DBP, respectively), heart rate, state anxiety, and health-related QOL
were measured at the baseline, 4-week follow-up, and 8-week follow-up. The effects of the
aroma foot massage intervention on these factors and the proportion of participants with
anxiety were analyzed using a linear mixed-effect model for a crossover design adjusted for
participant and period effects. Furthermore, the relationship between the changes in SBP
and state anxiety among participants with relieved anxiety was assessed using a linear
regression model.
Results
Aroma foot massage significantly decreased the mean SBP (p = 0.02), DBP (p = 0.006),
and state anxiety (p = 0.003) as well as the proportion of participants with anxiety (p =
0.003). Although it was not statistically significant (p = 0.088), aroma foot massage also
increased the score of mental health-related QOL. The change in SBP had a significant and
positive correlation with the change in state anxiety (p = 0.01) among participants with
relieved anxiety.
1 / 13
 The Effects of Aroma Massage on Blood Pressure and Anxiety

Competing Interests: The authors have declared Conclusion

that no competing interests exist.
The self-administered aroma foot massage intervention significantly decreased the mean
SBP and DBP as well as the state anxiety score, and tended to increase the mental health-
related QOL scores. The results suggest that aroma foot massage may be an easy and
effective way to improve mental health and blood pressure.

Trial Registration
University Hospital Medical Information Network 000014260

Introduction
Mental stress and anxiety are major causes of hypertension and mortality from cardiovascular
diseases. For example, the Whitehall II Study, a cohort study of 7268 British men and women,
showed that perception of stress was associated with an increased risk of coronary heart disease
and found that those with perceived stress had a double the risk of coronary heart disease than
those without perceived stress [1]. Moreover, acute mental stress has been shown to trigger car-
diac catastrophes such as acute myocardial infarction and sudden death [2]. According to
Walker et al., each year 14% of deaths worldwide (approximately 8 million deaths) are ascribed
to mental disorders such as anxiety and depression [3]. Furthermore, according to the Japanese
Ministry of Health, Labour and Welfare, in 2014, more than 60% of workers reported feeling
stress, anxiety, and worry. Therefore, it is important to reduce mental stress and anxiety to
increase quality of life (QOL) and prevent cardiovascular diseases.
Although aromatherapy is often referred to as complementary and integrative medicine, it
is one of the many ways to relieve mental stress. Aroma essential oils are generally inhaled or
massaged into the skin, and the oil vaporizes and stimulates the olfactory system [4]. Conse-
quently, according to a Cochrane review [5], essential oils have many effects including calming
and de-stressing effects as well as promoting relaxation and sleep. For example, a previous
study reported that inhalation of ylang-ylang, a frequently used aroma oil, decreased blood
pressure (BP) in healthy men who participated in a randomized controlled trial (RCT) [6].
Similarly, an RCT crossover study conducted with 36 female high school students showed that,
the stress levels in the intervention group decreased significantly compared to the placebo
group after inhalation of aroma essential oils [7]. Furthermore, studies have shown that ambi-
ent odors of lavender and orange decreased anxiety and lightened mood in a dental office [8],
and massages with aroma oils promoted skin absorption of the oils [9] stimulating blood and
lymphatic circulation, improving the oxygen and nutrient supply, relaxing muscle tone, and
relieving emotional stress [10]. One study found that receiving an aroma body massage once a
week for 4 weeks and applying aroma cream on the arms, legs, and abdomen daily reduced BP
among participants [10]. Similarly, an open, semi-comparative trial with 12 breast cancer
patients showed that anxiety, as measured by the State-Trait Anxiety Inventory (STAI), was
significantly reduced after a 30-minute aroma body massage by skilled therapists [11]. More-
over, aroma massages twice a week for 4 weeks improved prefrontal cortex dysfunction and
mild depression in 5 patients with depression [12]. These findings indicated that aroma mas-
sage is associated with a more relaxed mental condition as well as decreased BP and anxiety.
In light of these findings, the number of studies that have assessed the effect of aromather-
apy on BP and anxiety in healthy volunteers using RCT methods is limited although there are
many studies concerning the efficacy of aromatherapy. Accordingly, the aim of this study was

PLOS ONE | DOI:10.1371/journal.pone.0151712 March 24, 2016 2 / 13

 The Effects of Aroma Massage on Blood Pressure and Anxiety

to evaluate the effects of self-administered aroma foot massages on BP and anxiety in Japanese
community-dwelling men and women using a crossover RCT design.

Materials and Methods

The protocol for this study and supporting CONSORT checklist are available as supporting
information; see the S1 CONSORT Checklist, S1 Protocol, and S2 Protocol.

Ethics Statement
Ethical approval was obtained from the Human Ethics Review Committee of the Ehime Uni-
versity Graduate School of Medicine (approval number 1401001). Written informed consent
was obtained from all participants before the baseline examination, and this study conformed
to the Declaration of Helsinki guidelines.
We confirmed that all ongoing and related trials for this intervention were registered.
Because of inadequate information for registration, the date of registration was delayed until
after the enrollment of participants.

Inclusion and exclusion criteria

Men and women aged 20 to 70 who lived in or near Matsuyama, Ehime Prefecture, Japan were
eligible for inclusion in this study. A 72-year-old woman who insisted on participating in this
study was also included. Participants were excluded if they were pregnant, had tachycardia
(heart rate [HR] 110 beats/min), bradycardia (HR 50 beats/min), severe hypertension (sys-
tolic BP [SBP] 180 mmHg, diastolic BP [DBP] 110 mmHg), severe arrhythmia, or cardio-
vascular disease. Those who had already participated in a similar study conducted in 2012 as
well as those with a health condition prohibiting participation in this study were also excluded.

Subjects
Fifty-eight participants (5 men and 53 women) aged 27 to 72 were eligible for inclusion. As the
flowchart in Fig 1 shows, 1 woman was excluded because she declined to participate (n = 57),
and the remaining 57 participants were randomized into 2 intervention groups (n = 29 and
n = 28, respectively). One woman dropped out before the baseline examination because of
pregnancy and 1 woman dropped out because of a scheduling conflict (n = 27 and n = 28,
respectively). In addition, 3 women dropped out before the 4-week follow-up examination; 1
because of a health condition, and 2 because of a scheduling conflict (n = 27 and n = 25, respec-
tively). One woman dropped out before the 8-week follow-up examination because of a sched-
uling conflict (n = 27 and n = 24, respectively). No harm or side effects occurred throughout
the trial.

Study design
This study was a crossover RCT. Participants were recruited between July 1 and July 22, 2013
through flyers and newspaper advertisements. Information regarding sex, age, and SBP level
was obtained from the study application. Participants were randomly divided into 2 groups
stratified by sex, age (<50 years old and 50 years old), and SBP (<130 mmHg and 130
mmHg). The allocation of the 2 groups was carried out randomly using random numbers rang-
ing from 0 to 1 with a cutoff value of 0.5. An administrative staff member handled participant
enrollment and automatically allocated participants into 1 of the 2 groups based on the random
numbers generated by Excel. Participants were allocated into group A (n = 29) or group B
(n = 28) using a 1:1 ratio. The baseline examination was held on August 1 for group B and

PLOS ONE | DOI:10.1371/journal.pone.0151712 March 24, 2016 3 / 13

 The Effects of Aroma Massage on Blood Pressure and Anxiety

Fig 1. Flowchart and schedule of trial.

doi:10.1371/journal.pone.0151712.g001

August 6 for group A. The first follow-up examination (4-week follow-up) was held on Sep-
tember 1 for group A and on September 3 for group B. The second follow-up examination
(8-week follow-up) was held on September 29 for both groups. All examinations and interven-
tions were held at a fitness club in Matsuyama, Japan. The intervention sessions were con-
ducted between August 6 and September 1, 2013 for group A, and between September 3 and
September 29, 2013 for group B. The study schedule is shown in Fig 1. The sample size was
determined by a power calculation based on previous results regarding hypertension in mid-
dle-aged women. These results indicated that the mean BP decreased by 15 mmHg after aroma
massage [10]. Therefore, given that participants in our study were not patients, we presumed
that the decrease in BP would be less than in the aforementioned study and, thus, assumed a
decrease of 10 mmHg. With the standard deviation, significance level, and number of subjects
in the study at 12, 0.05, and 51, respectively, the power calculation in this study using a cross-
over design was 82.3%.

Interventions
After a 10-minute footbath, participants performed an aroma foot massage for 45 minutes on
themselves under the supervision of a well-trained instructor. First, participants put the oil on
their hands and inhaled the fragrance. Next, they applied the oil to their legs and massaged
them with sweeping and gliding strokes from their thighs to their toes using their fingers and
the palms of their hands. Participants also stimulated their acupuncture points at a moderate
pressure and speed. After the massage, participants laid on their back and relaxed for 5 min-
utes. The room temperature and humidity were 38˚C and 65%, respectively, (standard temper-
ature in many Japanese hot studios and considered the optimum temperature to promote

PLOS ONE | DOI:10.1371/journal.pone.0151712 March 24, 2016 4 / 13

 The Effects of Aroma Massage on Blood Pressure and Anxiety

perspiration during exercise). Participants were allowed to drink water and about 40 mL of hot
ginger water during the process. All participants performed these procedures 3 times a week
for 4 weeks (a total of 12 times) during the intervention period. These procedures were con-
ducted on Tuesdays, Thursdays, and Sundays, and participant attendance was recorded. Partic-
ipants who could not participate on the intervention days were allowed to participate on other
days during the same week. The aroma oil used in this trial was blended for relaxation as well
as mental and physical health by an aromatherapy specialist. Lavender, chamomile, sandal-
wood, ylang-ylang, and marjoram were blended with jojoba (a carrier oil) and preserved at
room temperature for use.

Measurements
Blood pressure and heart rate. After 5 deep breaths, SBP, DBP, and HR were measured
on the right arm using an automatic sphygmomanometer (BP-103i II, Omron Colin, Kyoto,
Japan) with participants in the seated position. After the first BP measurement, participants
took 2 deep breaths, and a second measurement was taken. The mean value of the 2 measure-
ments was used for the analyses.
State anxiety. The state anxiety and psychological stress scores were evaluated by the Japa-
nese version of the STAI (STAI–JYZ) [13,14]. The STAI is one of the most popular measures
of anxiety [15] and has been used worldwide because of its validity and reliability [13,16]. The
anxiety reflects ephemeral feelings (such as nervousness, worry, and tension) associated with
activation of the autonomic nervous system and indicates a participant’s recognition of stress-
ors in the environment at a particular moment [15]. The STAI-JYZ includes 20 questions, and
participants answered each question using a 4-point scale (not at all, somewhat, moderately so,
or very much so) resulting in a score ranging from 20 points to 80 points. A higher score indi-
cates greater anxiety. As described in the STAI-JYZ manual, which was referred to previous
research papers [13], scores of state anxiety were divided into the following 5 groups: group 1
(<35 points), group 2 (35–45 points), group 3 (46–54 points), group 4 (55–64 points), and
group 5 (65 points). These scores were categorized as low anxiety (groups 1 and 2) and high
anxiety (groups 4 and 5). In previous research, low anxiety was defined as 45 points or below.
Therefore, we classified participants with a state anxiety score of greater than 45 points as hav-
ing anxiety. We also calculated the change in the state anxiety score (values after the interven-
tion—values before the intervention). Finally, based on the change in the state anxiety score,
we divided participants into the following 2 groups using the median in intervention periods:
1) people with relieved anxiety (i.e., a change of less than -3) and 2) people without relieved
anxiety (i.e., a change of -3 or more).
Health-related QOL. Health-related QOL was measured by the 8-Item Short-Form
Health Survey (SF-8) [17,18]. The SF-8 is the reduced version of the Medical Outcomes Study
36-Item Short-Form Health Survey, which has been used for evaluating health conditions
worldwide. The Japanese version of the SF-8 was translated by Fukuhara et al. after a 2002
national survey (n = 1000) established the Japanese standards. The SF-8 has been used widely
because of its reliability [17]. The instrument includes 8 questions assessing the following
domains: physical functioning, role physical, bodily pain, general health perception, vitality,
social functioning, role emotional, and mental health. Each response uses a 5- or 6-point scale
and is normalized using the national standards. A score of 50 points represents the average Jap-
anese standard, and higher scores indicate a better QOL. The physical component summary
(PCS) encompasses the first 4 domains (physical functioning, role physical, bodily pain, and
general health perception), while the mental component summary (MCS) encompasses the lat-
ter 4 domains (vitality, social functioning, role emotional, and mental health).

PLOS ONE | DOI:10.1371/journal.pone.0151712 March 24, 2016 5 / 13

 The Effects of Aroma Massage on Blood Pressure and Anxiety

Lifestyle and physical examinations. Participants answered questions concerning lifestyle

and behaviors such as habitual alcohol intake, smoking status, habitual exercise, optimism,
subjective stress, stress relief methods, and satisfaction of sleep.
In the physical examination, we measured participants’ weight with bioelectric impedance
analysis using an InBody 730 (InBody Japan Inc., Tokyo, Japan). The body mass index was cal-
culated as weight/height (kg/m2).

Statistical analysis
Mean values of the baseline characteristics for group A and B were calculated and compared
using an unpaired two-tailed t-test or chi-square test. The intervention effects of aroma foot
massage on SBP and DBP, state anxiety, health-related QOL, and the proportion of partici-
pants with anxiety were analyzed using a linear mixed-effect model for a crossover design
adjusted for participant and period effects (combining group A and B). We also calculated the
intervention effects stratified by age group (i.e., <50 years old and 50 years old) and changes
in the SBP and state anxiety values (after intervention—before intervention). The relationship
between the 2 values among participants with relieved anxiety was assessed and shown graphi-
cally using a linear regression model. SAS statistical software version 9.4 (SAS Institute Inc.,
Cary, NC, USA) was used for analyzing the data. P-values less than 0.05 were considered
significant.

Results
Characteristics of participants at baseline
Participant characteristics at baseline are shown in Table 1. Participants were predominantly
female (90.9%) with a mean age of 48.9 years, body mass index of 21.6 kg/m2, SBP of 107.6
mmHg, DBP of 68.5 mmHg, HR of 71.0 beats/min, state anxiety score of 40.9, SF-8 PCS score
of 48.8, and MCS score of 46.0. There were no differences between group A and B at baseline.

Blood pressure
The mean SBP and DBP values at the baseline, 4-week follow-up, and 8-week follow-up exami-
nations in both group A and B as well as the intervention effects of aroma foot massage on BP
are shown in Table 2. The SBP and DBP values significantly decreased after the intervention.
The SBP of group A was 108.1 mmHg before and 107.0 mmHg after the intervention, while for
group B, it was 114.1 mmHg before and 110.0 mmHg after the intervention (p = 0.02). Simi-
larly, the DBP for group A was 69.2 mmHg before and 67.3 mmHg after the intervention,
while for group B, the DBP was 70.5 mmHg before and 68.8 mmHg after the intervention
(p = 0.006). An intervention effect on DBP was found in the older age group (group A:
before = 74.2 mmHg and after = 71.8 mmHg; group B: before = 76.3 mmHg and after = 73.7
mmHg; p = 0.01), but not in the younger age group. There were no significant changes in HR.

State anxiety and health-related QOL

The mean state anxiety and health-related QOL values at the baseline, 4-week follow-up, and
8-week follow-up examinations as well as the intervention effects of aroma foot massage on
these factors are shown in Table 2. There were significant improvements in the state anxiety
scores (group A: before = 41.1 and after = 38.0; group B: before = 40.0 and after = 35.0;
p = 0.003). In addition, there was significant elevation in the score for mental health of health-
related QOL (group A: before = 45.7 and after = 50.4; group B: before = 47.8 and after = 49.8;
p = 0.02). In addition, the MCS and the score for vitality showed increases although they were

PLOS ONE | DOI:10.1371/journal.pone.0151712 March 24, 2016 6 / 13

 The Effects of Aroma Massage on Blood Pressure and Anxiety

Table 1. Baseline characteristics of participants.

Baseline variables Group A (n = 27) Group B (n = 28) P value Total (n = 55)

Women, % 88.9 92.9 0.61 90.9
Age, years 49.0±13.6 48.8±11.4 0.95 48.9±12.4
Body Mass Index, kg/m2 21.0±2.5 22.1±3.2 0.16 21.6±2.9
Systolic blood pressure, mmHg 108.1±13.3 107.1±14.6 0.79 107.6±13.8
Diastolic blood pressure, mmHg 69.2±10.9 67.9±10.2 0.65 68.5±10.5
Heart rate, beats/min 73.9±11.8 68.2±10.4 0.06 71.0±11.4
Habitual alcohol intake, % 40.7 57.1 0.22 49.1
Smoking status, % 3.7 0.0 0.30 1.8
Habitual exercise, % 25.9 21.4 0.69 23.6
Optimistic, % 63.0 53.6 0.48 58.2
Subjective stress, % 22.2 14.3 0.45 18.2
Employing stress relief method, % 66.7 60.7 0.65 63.6
Satisfaction of sleep, % 55.6 57.1 0.91 56.4
State Anxiety (STAI) score 41.1±11.2 40.6±10.0 0.88 40.9±10.5
SF-8 Health Survey Scoring
Physical component summary 48.4±7.1 49.3±7.6 0.66 48.8±7.3
Mental component summary 44.7±8.3 47.2±7.1 0.24 46.0±7.7
Physical functioning 49.1±5.5 49.8±4.6 0.64 49.5±5.0
Role physical 47.6±6.1 49.2±5.3 0.31 48.4±5.7
Bodily pain 48.7±8.6 51.7±9.5 0.23 50.2±9.1
General health perception 48.4±6.7 48.2±7.7 0.92 48.3±7.1
Vitality 48.0±7.3 49.1±6.8 0.55 48.5±7.0
Social functioning 45.0±9.0 48.3±8.7 0.17 46.7±8.9
Role emotional 47.2±6.4 49.9±4.9 0.09 48.5±5.8
Mental health 45.7±6.9 47.6±6.5 0.29 46.6±6.7

Values are means ± standard deviation and ratios. P values indicate the significance of the differences between group A and B. STAI, State-Trait Anxiety
Inventory; SF-8, the 8-Item Short Form Health Survey.

doi:10.1371/journal.pone.0151712.t001

not statistically significant. The MCS in group A was 44.7 before the intervention and 49.5
after, while the score in group B was 47.3 before and 49.0 after the intervention (p = 0.088).
The score for vitality in group A was 48.0 before the intervention and 51.3 after, while the score
in group B was 50.3 before and 53.1 after the intervention (p = 0.05).There were also no signifi-
cant increases in the other domains of health-related QOL. After stratification by age group,
the results indicated an intervention effect on state anxiety in the younger group (group A:
before = 42.2 and after = 37.7; group B: before = 38.5 and after = 32.8; p = 0.004), but not the
older group.
The proportion of participants with anxiety after the intervention as well as the intervention
effect on state anxiety are shown in Table 3. There were significant decreases in the proportion
of participants with anxiety (group A: before = 40.7% and after = 25.9%; group B: before = 40.0%
and after = 16.7%; p = 0.003).

The relationship between changes in SBP and state anxiety

The relationship between changes in SBP and state anxiety in participants with relieved anxiety
is shown in Fig 2. The change in SBP had a significant and positive correlation with the change
in state anxiety (p = 0.01, n = 24).

PLOS ONE | DOI:10.1371/journal.pone.0151712 March 24, 2016 7 / 13

 The Effects of Aroma Massage on Blood Pressure and Anxiety

Table 2. Average blood pressure and mental health scores for the baseline, 4-week and 8-week follow-up examinations in group A and B.

Examination Changes

Variables Intervention Baseline 4-week 8-week Intervention Non-intervention P

group follow-up follow-up period period value
Number A 27 27 27 27 27
B 28 25 24 24 25
Systolic blood A 108.1 107.0±13.0 109.5±13.4 -1.07 2.43 0.02
pressure, mmHg ±13.3
B 107.1 114.1±16.4 110.0±16.3 -3.52 6.20
±14.6
Diastolic blood A 69.2±10.9 67.3±10.9 69.3±9.8 -1.87 2.00 0.006
pressure, mmHg
B 67.9±10.2 70.5±9.9 68.8±8.8 -1.38 2.18
Heart rate, beats/ A 73.9±11.8 72.7±9.6 72.9±10.7 -1.26 0.22 0.15
min
B 68.2±10.4 72.8±10.2 76.1±10.5 3.40 4.40
State Anxiety A 41.1±11.2 38.0±9.4 40.4±10.0 -3.04 2.41 0.003
(STAI) score
B 40.6±10.0 40.0±9.2 35.0±9.5 -5.17 -0.16
SF-8 Health Survey
Scoring
Physical A 48.4±7.1 49.6±5.9 49.7±5.2 1.20 0.13 0.72
component
summary
B 49.3±7.6 50.7±4.8 51.4±5.2 0.53 1.67
Mental component A 44.7±8.3 49.5±6.3 48.4±6.8 4.81 -1.15 0.088
summary
B 47.2±7.1 47.3±5.0 49.0±5.1 1.63 -1.09
Physical A 49.1±5.5 50.3±4.6 48.9±4.8 1.20 -1.44 0.11
functioning
B 49.8±4.6 49.9±4.3 50.9±4.7 0.91 0.21
Role physical A 47.6±6.1 49.8±4.6 49.8±4.0 2.19 0.03 0.98
B 49.2±5.3 50.4±3.6 50.5±5.2 -0.22 0.88
Bodily pain A 48.7±8.6 51.7±7.1 51.7±7.1 3.01 0.00 0.80
B 51.7±9.5 53.4±6.9 53.0±8.2 -0.65 1.83
General health A 48.4±6.7 50.9±8.1 51.4±7.3 2.53 0.45 0.15
perception
B 48.2±7.7 50.0±7.4 53.1±5.9 3.46 1.32
Vitality A 48.0±7.3 51.3±5.9 51.1±6.6 3.33 -0.22 0.05
B 49.1±6.8 50.3±5.9 53.1±4.6 2.98 0.77
Social functioning A 45.0±9.0 49.9±7.1 49.2±6.3 4.93 -0.74 0.26
B 48.3±8.7 48.7±7.2 50.6±6.7 1.11 -0.42
Role emotional A 47.2±6.4 50.3±5.1 50.0±3.8 3.12 -0.30 0.94
B 49.9±4.9 50.2±3.5 49.9±6.3 -0.56 -0.60
Mental health A 45.7±6.9 50.4±5.8 48.5±8.3 4.70 -1.83 0.02
B 47.6±6.5 47.8±5.3 49.8±5.7 2.05 -0.59

Data are represented as means ± standard deviation and mean change. P values indicate the intervention effects of changes in the intervention and non-
intervention periods (combining group A and B) analyzed using a linear mixed-effect model. Changes in the intervention period were based on the 4-week
follow-up—baseline examinations of group A and the 8-week follow-up—4-week follow-up examinations of group B. Changes in the non-intervention
period were based on the 8-week follow-up—4-week follow-up examinations of group A and the 4-week follow-up—baseline examinations of group B.
STAI, State-Trait Anxiety Inventory; SF-8, the 8-Item Short Form Health Survey.

doi:10.1371/journal.pone.0151712.t002

PLOS ONE | DOI:10.1371/journal.pone.0151712 March 24, 2016 8 / 13

 The Effects of Aroma Massage on Blood Pressure and Anxiety

Table 3. Proportion of participants with anxiety at baseline, 4-week and 8-week follow-up examination in group A and B.

Examination

State anxiety score Intervention group Baseline 4-week follow-up 8-week follow-up P value
 45, % A (n = 11) 40.7 25.9 40.7 0.003
B (n = 11) 39.3 40.0 16.7

The p value indicates the intervention effect between the intervention and non-intervention periods (combining group A and B) analyzed using a linear
mixed-effect model.

doi:10.1371/journal.pone.0151712.t003

Discussion
The present study demonstrated that 12 self-administered aroma foot massage sessions over
4-week period significantly improved SBP, DBP, state anxiety, and mental health-related QOL
among Japanese community-dwelling men and women. Self-administered aroma foot massage
may be an effective way to improve mental health and BP.
A previous study has indicated that practitioner-conducted aroma body massages adminis-
tered as a total of 5 sessions once a week for 4 weeks in addition to applying aroma cream on
the arms, legs, and abdomen daily while also avoiding excessive exercise and dieting, decreased
SBP by 15 mmHg in 28 middle-aged hypertensive women [10]. In our study, participants
applied aroma oil on the legs 12 times over 4 weeks resulting in SBP and DBP reductions of 2
mmHg on average. Although the reductions of BP in our study were smaller than in other stud-
ies, this could be because most of the participants had a normal BP at baseline (the average SBP
and DBP at baseline was 107.6 mmHg and 68.5 mmHg, respectively) and the intervention
methods were different, which makes comparisons between the studies difficult. Our interven-
tion may be easier and less expensive for the public. Other non-medical treatments that prevent
hypertension, such as changes to an unhealthy diet, reducing excessive energy intake, increas-
ing physical activity, and decreasing tobacco use [19], are not easy to maintain [20]. In contrast,
our trial suggested that performing self-administered aroma foot massages is easy and may
improve BP more than other interventions that require participants to make a lifestyle change.

Fig 2. The relationship between changes in SBP and state anxiety in participants with relieved
anxiety. The change in SBP had a significant and positive correlation with the change in state anxiety
(p = 0.01) among participants with relieved anxiety (changes in state anxiety score <-3) after the intervention.
doi:10.1371/journal.pone.0151712.g002

PLOS ONE | DOI:10.1371/journal.pone.0151712 March 24, 2016 9 / 13

 The Effects of Aroma Massage on Blood Pressure and Anxiety

Furthermore, to stimulate the olfactory system, we included lavender, ylang-ylang, marjo-

ram, sandalwood, and chamomile in the aroma oil blend. Lavender relaxes the autonomic ner-
vous system [21], calms and relaxes the level of emotion [22], and alleviates insomnia [9],
while ylang-ylang decreases BP and HR [6], and reduces depression and stress [23]. Accord-
ingly, reductions in BP and anxiety levels after our intervention might be because of lavender
and ylang-ylang. In addition, the effects of linalyl acetate and linalool, which are major compo-
nents of lavender and ylang-ylang essential oils [24,25], have been reported to affect the auto-
nomic nervous system, especially the vagal tone [26,27], and decrease BP [27]. Therefore, the
reductions in SBP and DBP in this study may be because of the activation of the vagal tone by
linalyl acetate and linalool, thus making them beneficial depressors of BP and anxiety. Further-
more, some studies have shown that marjoram reduces BP in rats [28] and improves insomnia
and sleeplessness through sedative effects [9]. In our study, improvements in SBP and DBP
might also be associated with the effects of marjoram. In addition, the sedative effects of san-
dalwood extracts [29–31] and the use of chamomile, which has been shown to improve anxiety
[32] and subjective sleep [33], and has antidepressant [34] and anxiolytic effects [35], may have
improved anxiety scores among participants. Thus, the combination of various oils may have
influenced relaxation, and improved BP and anxiety levels in this study. Furthermore, the com-
bination of aromatherapy with massage therapy might improve BP and mental health through
promoted absorption of the aroma oil by the skin and enhanced the calming and de-stressing
effects through stimulation of the olfactory system [9].
We aimed to assess the effects of self-administered aroma foot massages on anxiety. Ima-
nishi et al. showed that state anxiety was reduced after an aroma massage intervention among
breast cancer patients [11] and Bagheri-Nesami et al. reported that anxiety was decreased after
a foot reflexology massage intervention among 80 patients who underwent coronary artery
bypass graft surgery [36]. Similarly, the average state anxiety scores and the proportion of par-
ticipants who had state anxiety in this study decreased after the intervention, supporting results
from previous studies. In addition, our study focused on community-dwelling participants, not
hospitalized patients, and revealed the effectiveness of aroma massages in reducing anxiety
among this population. Furthermore, Au et al. found that anxiety following surgery was
relieved by acupressure in 5 RCT studies [37], and this may help explain the reduction of state
anxiety scores after aroma foot massage in this study. In other words, the reduction found in
this study might be partially contributable to stimulation of acupuncture points as well as
aroma foot massage. Moreover, an RCT conducted by Varney and Buckle found that inhaling
aromas 3 times a day for 3 weeks reduced mental exhaustion among 13 women and 1 man
with mental exhaustion or moderate burnout [38]. Similarly, vitality increased after this inter-
vention. In this study, the changes in SBP and state anxiety scores improved in participants
whose anxiety was relieved after the intervention. As some other research has also shown that
BP decreased on reducing anxiety [39,40], we presume that the primer change was reduction of
anxiety followed by decrease of blood pressure. Thus, aroma foot massages may be efficacious
in improving BP through reducing anxiety and improving the mental condition. Finally, an
intervention effect was found on state anxiety in the younger group and on DBP in the older
group reflecting effect differences according to age group.
This study has several strengths. First, to our knowledge, this was the first study to reveal
positive effects of aroma massage on BP and anxiety in community-dwelling men and women
(i.e., not ambulatory patients or inpatients) using a crossover RCT. Second, the aroma foot
massage intervention could be easy to implement because it is easily conducted at home by the
individual.
However, there are also some limitations to this study. First, because participants applied
for the study themselves through flyers and newspaper advertisements and the trial schedule

PLOS ONE | DOI:10.1371/journal.pone.0151712 March 24, 2016 10 / 13

 The Effects of Aroma Massage on Blood Pressure and Anxiety

was during weekdays, they may have been more health-oriented than the general population
and predominantly women who were interested in aroma foot massage, although the age and
range were wide. Therefore, we may have underestimated the size of the effect and we need to
consider the difference in the influence of specific age categories or sex when this intervention
is implemented publicly. Second, it was difficult to differentiate the effects of the aromatherapy
from the effects of the massage therapy; however, we hypothesized that a combination of
aroma and massage therapy may have increased the effectiveness of the intervention. Finally,
our study lacked a washout period before and after the 4-week follow-up. In group A, the aver-
age BP decreased after the intervention period but returned to baseline levels after the 8-week
follow-up. However, the effect of the lack of a washout period was kept to a minimum because
we adjusted for participant and period effects using the RCT study design.
In conclusion, our study showed that a self-administered aroma foot massage intervention
conducted 3 times per week for 4 weeks improved BP, anxiety, and health-related QOL. Self-
administered aroma foot massage may be easier to administer and may be an effective way to
increase mental health and improve BP.

Supporting Information
S1 CONSORT Checklist. CONSORT checklist.
(DOC)
S1 Protocol. Trial protocol. Study protocol in English.
(DOCX)
S2 Protocol. Trial protocol. Study protocol in Japanese.
(PDF)

Acknowledgments
The authors would like to thank Mr. Mitsunobu Goto, chief executive officer of the fitness
club, Sora to Mori REN, and other staff for their continuous support. For providing valuable
advice and cooperation throughout this study, we would like to express our sincere gratitude to
Dr. Hiroyasu Iso, Professor of Public Health, Department of Social Medicine, Osaka University
Graduate School of Medicine; Dr. Isao Saito, Professor of Community Health Systems Nursing,
Ehime University Graduate School of Medicine; Dr. Koutatsu Maruyama, Assistant Professor
of Public Health, Juntendo University Graduate School of Medicine; Dr. Masayuki Kubo and
Dr. Kenjiro Nagaoka, Asistant Professors of Public Health, Okayama University Graduate
School of Medicine, Dentistry and Pharmaceutical Sciences; Dr. Hiromi Mori, Ehime Univer-
sity Graduate School of Medicine; Dr. Kana Higuchi, Department of Basic Nursing and Health
Science, Ehime University Graduate School of Medicine; and to the following students of
Ehime University who participated in this study; Kaori Akiyama, Ayano Otaki, Haruki Oht-
subo, Hikaru Okabe, Kyosuke Habu, Kanako Fukuoka, Yuki Yokomoto, Hitomi Aono, Maho
Akimoto, Natsumi Arai, Ayumi Ito, Riko Katsube, Yukako Honbo, Akiko Yano, Tomoko
Yoshihara, Yu Inoue, Tsuyoshi Ohno, Shiro Ogawa, Yuichiro Shimada, Soichiro Nishihara,
Genta Fukumoto, Syouta Miyoshi, Marika Matsuoka and Shota Kikuchi.

Author Contributions
Conceived and designed the experiments: EE. Performed the experiments: EE KT. Analyzed
the data: EE NF KT. Contributed reagents/materials/analysis tools: TO TT. Wrote the paper:
NF. Critical revision of the article: EE NF KT TO KO TT.

PLOS ONE | DOI:10.1371/journal.pone.0151712 March 24, 2016 11 / 13

 The Effects of Aroma Massage on Blood Pressure and Anxiety

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Med. J. Cairo Univ., Vol. 79, No. 2, September: 193-202, 2011
www.medicaljournalofcairouniversity.com
Effect of Nursing Interventions Using Foot Reflexology on
Blood Pressure and Quality of Life of Hypertensive Patients
at Mansoura University Hospitals: Preliminary Results
KARIMA ELSHAMY, D.N.Sc.* and EMAN ELSAFETY, M.D.**
The Departments Adult Nursing* and Cardiovascular Medical**, Faculty of Nursing, Mansoura University, Egypt
Abstract
The aim of this study was to investigate the effect of foot
reflexology on blood pressure and quality of life among
hypertensive patients. A quasi-experimental study was con-
ducted for patients with hypertension attended the outpatient
clinic of the Specialized Medical Hospital at Mansoura Uni-
versity, Egypt, enrolled in this study during six months,
between 15 May and 14 October 2010 were randomly allocated
into two equal groups (40 in the foot reflexology group
(intervention), and 40 in the control group.
Two tools were used for data collection:
I : Demographic and medical interview schedule.
II: Quality of Life Questionnaire.
Systolic blood pressure decreased significantly in inter-
vention group from 160.2mmHg to 136.5mmHg compared to
(162.5mmHg to 155.2mmHg) in controls. There was a statis-
tically significant decrease in means of diastolic blood pressure
between pre and post intervention (102.0mmHg –87.5mmHg)
within the intervention group ( p<0.05), Change in control
group was not proved to be statistically significant
(100.1mmHg –96.4mmHg pre and post readings respectively,
p>0.05). There was no evidence for improvement in Quality
of Life in either group (pre levels was 42.2, 47.1 and post
levels was 45.9, 47.4 in the 2 groups respectively). This study
supported that foot reflexology can reduce blood pressure
levels in patients with hypertension, it did not support that
foot reflexology could improve quality of life in these patients.
Future research is needed to support these findings specially
the negative ones. It is recommended that qualitative research
might be used in combination with quantitative research to
determine details of patients' feelings, interactions, attitudes,
cultural influences and satisfaction after intervention.
Key Words: Nursing Intervention – Foot reflexology – Hyper-
tension – Blood pressure – Quality of life.
Introduction
HYPERTENSION is one of the conditions pur-
ported to be improved by complementary therapies
such as foot reflexology [1,2] . Hypertension is
Correspondence to: Dr. Karima Elshamy, Adult Nursing
Department, Faculty of Nursing, Mansoura University,
Email: Karima_elshamy2002@yahoo.com
193
defined as a condition in which individuals have
a systolic pressure of equal to or greater than
140mmHg and a diastolic pressure of equal to or
greater than 90 mmHg on at least three occasions,
or individuals who require medication to remain
normotensive [3-5] .
Hypertension is one of the conditions purported
to be improved by complementary therapies such
as foot reflexology [1,2] . Pressure techniques applied
on the feet are believed to help unblock nerve
supply and improve blood flow, which may help
the body to function at its peak 1. It is claimed
that reflexology relieves stress and tension by
inducing relaxation [1,6] . By doing this, it brings
about vasodilatation, blood pressure, improved
blood flow and provision of oxygen-rich nutrients
to cells [1,7,8] . Some authors suggest that 70 to
80% of all diseases and illnesses come from stress
including hypertension, migraine, headaches, the
common cold, ulcers and coronary heart disease
[1,9] .
Although not yet widely used, relaxation tech-
niques are potentially valuable nonpharmacological
treatments to lower blood pressure. Such techniques
include progressive muscle relaxation, etc ... [10] .
Complementary therapies such as massage and
reflexology are claimed to help reduce symptoms
of stress and tension resulting in a decrease in
blood pressure, and an adjustment of body, mind
and spirit to a state of harmony [11] ; they can also
help improve quality of life [12] .
Reflexology is believed to be used for more
than 4,500 years in Egypt, as pictograph evidence
was found in the tomb of an Egyptian physician;
some claim that it originated in India and China
[2,6] . During intervention, the therapist inserted
pressure on reflexology areas of plantar surface of
194 Effect of Nursing Interventions Using Foot Reflexology on Blood Pressure
the feet or palm of the hands using his fingers
(specially the thumbs) which were related to each
part of the body. This caused health restore and
had made a balance throughout the body [13,14] .
Reflexology, as a comprehensive approach and
a nursing intervention that supports traditional
care; can be used in the medical treatments [15,16] .
Many studies have investigated reflexology as a
noninvasive and non-pharmacological nursing
intervention in its various aspects such as: The
impact of reflexology on hypotension without any
known reasons, reducing triglyceride and blood
sugar, improving nausea and vomiting in cancer
patients undergoing chemotherapy, reducing de-
pression and improving immune system function,
improving pain and anxiety of the cancer patients
and decrease the fatigue in pregnant women [17] .
However, in a pilot (small) study conducted on the
anxiety of patients before and after the coronary
artery bypass graft surgery, this method has a
significant effect on the physiological parameters
of the patients [11] .
It has been found that health care professionals
have increased their use of complementary therapies
to help relieve uncomfortable symptoms and suf-
fering of patients with chronic diseases [18] . Foot
reflexology is a well known complementary therapy
which claims to help the body achieve homeostasis.
It is believed that pressing specific areas on the
feet related to specific glands or organs of the body
can help these glands and organs to function at
their peak, allowing the body to heal itself [1,2] .
The principal difference between massage and
touch and foot reflexology is that foot reflexology
provides not only the relaxation effect obtained
from massage or touch but is said to also improve
body immunity contributing to healing process
[1,2] . Foot reflexology has been scientifically re-
searched in many studies to explore the claimed
benefits [19,20] . Some studies have supported its
ability to reduce anxiety and pain [21-23] . However,
there has been little scientific evidence to support
the claim that foot reflexology can reduce blood
pressure and serum lipids, and can improve the
quality of life in patients with hypertension [21-
24] . The purpose of this study was to begin to fill
this gap by investigating the influence of foot
reflexology on blood pressure, serum lipids and
quality of life in hypertensive patients.
The role of nursing staff is to care for patients
as a whole, encompassing body, mind and spirit
[24] . Demonstrating concern for patients’ needs
helps to achieve holistic care [25] . Patients with a
chronic disease, who are suffering not only from
the disease and any treatment side effects but may
also, be worried and frustrated about their disease,
may be open to complementary therapies as an
adjunct to conventional treatments.
The aim of this study was to: Investigate the
effect of foot reflexology on decreasing blood
pressure and the improvement in mean quality of
life among hypertensive patients.
Hypotheses:
1- There will be a decrease in mean blood pressure
level in foot reflexology group (intervention)
relative to the control group (no intervention)
by the end of four weeks of implementation.
2- There will be an improvement in mean quality
of life scores in foot reflexology group (inter-
vention) relative to the control group (routine
management) by the end of four weeks of im-
plementation.
Subjects and Methods
Research design: A quasi-experimental, pro-
spective study was conducted for patients with
hypertension enrolled in this study. Two groups
were studied; foot reflexology group (intervention)
and control group (routine management). All pa-
tients continued their usual medical treatment
throughout the duration of the study.
Subjects and setting: The subjects of this study
consisted of 80 consecutive eligible patients with
hypertension who attended the outpatient clinic of
the Specialized Medical Hospital at Mansoura
University, Egypt; Subjects were matched and
similar in gender, age, educational background,
economic factors, marital status, duration of hy-
pertension, medical history and treatments, lifestyle
characteristics, and co-morbidities. Patients were
randomly allocated and divided to equal numbers.
into 40 patients in intervention and control group.
Data collection was undertaken during six months,
between May and October 2010. Subjects were
eligible for inclusion in the study if they were:
Adult males and females, aged 18 years and above,
had hypertension (systolic blood pressure greater
than or equal to 140mmHg, and diastolic blood
pressure greater than or equal to 90mmHg) with
or without hyperlipidaemia, had two feet, gave
informed consent to be involved in the study and
fully conscious. Subjects were excluded from the
study if they had thrombotic disease of the lower
extremities, foot ulcers, foot infections/diseases,
or had undergone foot surgery, and pregnant women
were excluded. Other criteria of exclusion were:
recent major surgery such as open heart surgery,
Karima Elshamy & Eman Elsafety
lesions or fractures in foot, sprains or bruises of
the lower extremities, hemorrhage, epilepsy, dia-
betic foot complication, thrombosis, kidney stone
or gallbladder, irregular heart rate and hypotension
[26,27] . Patients with open skin wounds on their
feet, a foot tumor or foot metastasis, or radiation
treatment to the feet was also excluded [28] .
Tools of the study:
Two tools were used in the study:
Tool I: Demographic and medical interview sched-
ule:
A demographic data questionnaire was written
in Arabic language, This tool was developed by
Soliman H. (2007) in a pervious study which in-
cluded questions on gender, age, marital status,
educational background, economic factors (specif-
ically, whether patients had financial problems),
duration of hypertension, medical history and
treatments, co-morbidities, and top medical treat-
ments. It also included questions about lifestyle
modification such as fat/salty foods intake, exercise,
smoking, alcohol intake, recreation and relaxation.
This questionnaire was completed by participants
at the first day of the study [29] .
Tool II: Quality of life questionnaire:
The World Health Organization Quality of Life-
BREF, Arabic version (WHOQOL-BREF) ques-
tionnaire was used. The WHOQOL-BREF is a 26-
item, self-administered, generic questionnaire that
is a short version of the WHOQOL-100 scale. The
response options range from 1 (very dissatisfied/
very poor) to 5 (very satisfied/very good). It consists
of domains and facets (or sub-domains). The items
on “overall rating of QOL” (OQOL) and subjective
satisfaction with health constitute the general facet
on OQOL and health. The more popular model for
interpreting the scores has four domains, namely,
physical health (seven items), psychological health
(six items), social relations (three items) and envi-
ronment (eight items). Participants completed this
questionnaire at the start of the study and following
four weeks of intervention [30] .
Methods:
Official permission to conduct the study was
taken from the hospital responsible authorities
after explaining study’s aims.
Content validity: The content validity of the
first tool along with the including and excluding
criteria was submitted to 10 experts in the field of
medical surgical nursing, medicine and physiother-
apy for their opinion on the items in the tool and
the criteria. There was complete agreement by
195
experts and minimal modifications were made
based on the given suggestion.
Reliability of the tool: A new standardized
sphygmomanometer and stethoscope were used to
check the blood pressure. The reliability of the
sphygmomanometer and stethoscope were checked
with other standardized sphygmomanometer and
stethoscope. The readings were matched with the
comparative devices used for the reliability testing.
Pilot study: A pilot study was conducted in the
previously mentioned setting, from 5 May 2010
to 10 May 2010. The investigator obtained formal
permission from the concerned authority prior to
the study. The study was conducted on 10 hyper-
tensive patients who fulfilled the inclusion criteria
for the selection of the sample. The purpose of the
study was explained to the subjects and consents
were obtained after assuring privacy and confiden-
tiality. Baseline information was collected; and
blood pressure was checked after intervention. The
tools were found feasible and practical. No further
changes were made in the tool after the pilot study
and the investigator proceeded for the main study.
Before taking part in the study, all potential
participants were provided with information about
the study topic; the study objectives, study meth-
odology, potential risks, and treatment benefits,
privacy and confidentiality were assured. Patients
who accepted to participate were assured that their
participation was entirely voluntary and informed
of their rights as research subjects. The investigator
clarified this information verbally and provided
further details upon request. Patients who wished
to participate in the study were asked to give
consent to confirm their willingness to be involved
in the study. They were also informed that they
could withdraw from the study at any time without
any impact on their treatment.
Prior to randomization, participants were asked
to complete a demographic data questionnaire and
the World Health Organization Quality of Life-
BREF (WHO QOL BREF) questionnaire. Revision
of their laboratory data for: A blood sugar, kidney
function, lipids and gout. Electrocardiogram was
also done for all participants in the study to exclude
patients with irregular heart rate.
Eligible participants were randomly allocated
into two equal groups 40 participants in the foot
reflexology group (intervention) and 40 in the
control group (routine management). Immediately
prior to each treatment session, patients were
provided with 10-minute rest. Following this rest
time, their blood pressure level was measured by
196 Effect of Nursing Interventions Using Foot Reflexology on Blood Pressure
trained nurses in the outpatient clinic using a
standard mercury sphygmomanometer and stetho-
scope before and after each treatment.
The researchers worked to decrease factors
affecting blood pressure such as emotion, exercise,
respiration, meals, tobacco, alcohol, temperature,
pain, bladder distension based on the protocols for
taking blood pressure [31] . The sphygmomanometer
was calibrated before use.
The process of reflexotherapy was explained
to the intervention group. Participants in the foot
reflexology group received their usual medical
treatment and a 30-minute foot reflexology treat-
ment (15m for each foot) twice a week for four
weeks. Participants in the control group received
their routine usual medical treatment which includ-
ed physical examination of feet.
The research assistant conducted the reflexo-
therapy; first of all, the relaxation technique was
used from the footstalk toward the sole (plantar
surfaces) at the beginning of the session. Then,
four major plantar reflexology points (solar plexus,
pituitary, heart and liver) were put under pressure
using the thumbs. The other reflexology areas of
the plantar surface of the foot were also massaged
and finally intervention was put to an end with
massaging the solar plexus by the researcher.
At the end of the study (4 weeks), immediately
after the intervention, blood pressure level was
measured again by the by the research assistant in
the clinic. Participants were asked to complete the
WHO QOL-BREF again. After data collection,
patients in the control group received the same
foot reflexology to avoid depriving them from a
potentially valuable technique.
Foot reflexology procedure:
Prior to the study the investigator underwent
2-hours training on foot massage under an expert
in the Physiotherapy Department of Faculty of
Medicine, Mansoura University.
The researcher follows Farnsworth’s method; the
researcher starts at the right foot as follows:
Relaxing techniques: 1. Ankle stretch ‘under’.
2. Ankle stretch ‘over’. 3. Ankle loosening. 4. Side
to side. 5. Spinal stretch. 6. Metatarsal knead. 7.
Diaphragm relaxer. 8. Toe rotation [32] .
Working the spine: 1. Toe walk up sacral-coccyx
zone. 2. Toe walk up lumbar zone. 3. Toe walk up
thoracic zone. 4. Finger walk up cervical zone. 5.
Toe walk down thoracic zone. 6. Toe walk down
lumbar, sacral-coccyx zone. 7. Spinal stretch and
metatarsal knead [32] .
Working the lungs: 1. Diaphragm relaxer then
toe walks from medial metatarsal upwards from
diaphragm to base of toes. 2. Do five plantar zones
in between metatarsals; repeat other hand, back to
start metatarsal knead. 3. Finger walk dorsal five
zones in between metatarsals with thumb in fist
medial to lateral. 4. Change hands, repeat lateral
to medial.
Working the toes: 1. Toe walk sideways over
throat-thyroid reflex both ways. 2. Finger walk
cervical while stretching toe with holding fingers.
3. Toe walk down large toe plantar side latched
onto fingers, work medial to lateral. All toes latched
onto fingers, work medial to lateral all toes to their
roots. 4. Repeat other coming back to start (use
other hand). 5. Hook in and back up on pituitary
with medial thumb. 6. Working the brain. 7. Toe
walk the ridge (eye and ear reflexes) both ways
using lateral aspect or edge of thumbs pulling down
padding. 8. Side to side relaxer. 9. Metatarsal
kneads [32] .
Working the digestive system: 1. Toe walk waist-
line to diaphragm, cross hatch in both direction
with foot in dorsiflexion. 2. Wring out with thumbs.
3. Toe walk waistline to heel line, cross hatch in
both directions with foot in dorsiflexion and wring
out with thumb. 4. Work the adrenal gland. 5. Work
the ileocecal valve reflex hook in and back up right
foot. 6. If on left foot cross hatch plantar heel zone
working the sigmoid flexor three ways with thumb
then hook in and back up. 7. Side to side relaxer
[32] .
Working the lateral and medial heel areas: 1.
Finger walk lateral hip, knee, leg reflex zone. 2.
Change hands and finger walk same reflex from
dorsal side to plantar side. 3. Finger walk hip,
sciatic reflex around external malleolus. 4. Change
hands and finger walk same reflex going opposite
direction underneath. 5. Change hands pin point
with index finger rotate clockwise on lateral repro-
ductive reflex. 6. Ankle loosening. 7. Dorsiflex
foot, toe walk medial Achilles tendon three times.
8. Reflex rotate using thumb as a fulcrum on medial
reproductive reflex. 9. Ankle loosening. 10. Finger
walk across ankle medial to lateral and lateral to
medial. 11. Finish with full range of relaxing
techniques [32] .
Statistical methods:
Random number tables were used to allocate
consecutive eligible patients to either group.
Karima Elshamy & Eman Elsafety 197

Descriptive statistics included numbers and
percentages for qualitative variables and means
and standard deviations for quantitative variables.
Comparison of means was achieved using 2-tail t-
test for independent samples. Chi-square test was
used to compare percentages. The threshold of
significance was fixed at the 5% level [33,34] .
Results
Demographic characteristics of participants:
For this study, the 80 participants were randomly
allocated into two groups: (40 in the foot reflexol-
ogy group (intervention), and 40 in the control
group (routine management).
Demographic data for the participants was
collected and then analyzed for gender, age, marital
status, educational background, economic factors,
duration of hypertension, medical history, period
of treatment for hypertension, and co-morbidities.
Lifestyle data such as fat/salty foods intake, smok-
ing, alcohol intake, exercise and recreation / relax-
ation was also determined. The data is presented
in Tables (1-6).
control group. These results may be related to
Egyptian culture and religion. Most of participants
(67.5%) in the foot reflexology group and 70.0%
of participants in the control group had a sedentary
lifestyle, exercising less than once a week. More
than 80% of participants in each group had recre-
ation or relaxation time more than once a week
90.0% in the foot reflexology group, 87.5% in the
control group (Table 2).
Top six co-morbidities of the two study groups:
There was no difference in both groups related to
the top six co-morbidities and also other co-
morbidities. Some participants had more than one
of co-morbidity, thus the total does not equal 100%.
The most co morbid was diabetes 75.0% and 72.5
(Table 3).
Table (1): Demographic and clinical characteristics of the
studied groups N=80.
Foot Control
Reflexology Group N=40
Characteristic Group N=40 (Routine
(Intervention ) management)

N % N %
Demographic data of control and intervention
groups were similar without statistically significant Gender:
differences in gender, age, educational background, Male 27 67.5 26 65.0
Female 13 32.5 14 35.0
economic factors, lifestyle characteristics, co-
morbidities and medical treatments, marital status, Age/year:
the length of time experiencing hypertension and 30-40 years 10 25.0 10 25.0
40-50 years 12 30.0 12 30.0
the length of time having treatment for hyperten- 51-60 years 19 47.5 18 45.0
sion.
Marital status:
Demographic characteristics of the studied Single 4 10.0 5 12.5
Married 31 77.5 30 75.0
groups (n=80): Most of patients were married in Divorced/separated/ 5 12.5 5 12.5
foot reflexology and control group (77.5%) and widowed
(75.0%). Both groups reported achieving similar
Level of education:
levels of university education 53.7% and 52.5% No education 5 12.5 5 12.5
of in the foot reflexology group and control group Primary school 1 2.5 2 5.0
respectively. The majority of participants in both Secondary school 13 32.5 13 32.5
groups had financial problems – 90.0% in the foot College/university 22 55.0 21 52.5
reflexology group, 87.5% in the control group. Economic/financial
There was no difference between the groups in the difficulties:
length of time that participants had been diagnosed Yes 36 90.0 35 87.5
No 4 10.0 5 12.5
with hypertension, and the duration having treat-
ment for hypertension (Table 1). Duration of hypertension/
year:
Lifestyle characteristics of the studied groups 1-5 years 20 50.0 21 52.5
(n=80): Almost more than 70% of participants in 6-10 years 10 25.0 9 22.5
10-15 years 3 7.5 3 7.5
the two groups ate fat/salty foods more than 1- More 15 years 8 20.0 7 17.5
6/wk – 82.5 % in the foot reflexology group, 85.0%
Treatment of hypertension/
in the control group. Most participants did not year:
smoke – 55.0% and 55.0% in the foot reflexology 1-5 years 19 47.5 18 45.0
and control groups respectively. The majority of 6-10 years 11 27.5 12 30.0
participants did not drink alcohol at all – 98.0% 10-15 years 5 12.5 4 10.0
in the foot reflexology group and 99.0% in the More 15 years 5 12.5 6 15.0
198 Effect of Nursing Interventions Using Foot Reflexology on Blood Pressure

Table (2): Lifestyle characteristics of the studied groups N=80. and post intervention (160.2mmHg versus 136.5
Foot Control mmHg) within the intervention group respectively
Reflexology Group N=40 (p<0.05). Change in control group was not proved
Characteristic Group N=40 (Routine to be statistically significant (162.5mmHg-155.2
(Intervention ) management) mmHg pre and post readings respectively) ( p>0.05).
N % N %
There was a statistically significant decrease
Fat/salty foods intake: in means of diastolic blood pressure between pre
Never 0 0.0 0 0.0
and post intervention (102.0mmHg versus 87.5
<1/wk 2 5.0 0 0.0
1-6/wk 33 82.5 34 85.0
mmHg) within the intervention group (p<0.05),
Daily 5 12.5 6 15.0 Change in control group was not proved to be
statistically significant (100.1mmHg versus 96.4
Smoking: mmHg pre and post readings respectively, p>0.05).
Yes 18 45.0 18 45.0
No 22 55.0 22 55.0
There was a little difference in means of quality
Alcohol intake: of life scores between groups before treatment.
Never 38 95.0 39 97.0 Differences was not proved to be statistically
<1/wk 2 5.0 1 2.5 significant (p>0.05).
1-6/wk 0 0.0 0 0.0
Daily 0 0.0 0 0.0
Mean of quality of life and health satisfaction
Exercise: scores were slightly higher for participants in the
Never 27 67.5 28 70.0 foot reflexology group than for participants in the
<1/wk 5 12.5 5 12.5 control group. Mean of physical health, psycho-
1-6/wk 6 15.0 6 15.0
logical health, social relationships and environment
Daily 2 5.0 1 2.5
scores for participants in the control group were
Recreation/relaxation: slightly higher than for participants in the foot
Never 1 2.5 1 2.5 reflexology group. Quality of life scores pre-post
<1/wk 36 90.0 35 87.5 intervention was neither statistically nor clinically
1-6/wk 3 7.5 4 10.0
significant. Differences were not proved to be
Daily 0 0.0 0 0.0
statistically significant (p>0.05).

Table (3): Top six co-morbidities of the studied groups N=80. There was a significant increase in all patients
comments before and after intervention in the foot
Foot reflexology group, (75.0%) of patients in the foot
Control
Reflexology
Group N=40 reflexology group feel satisfied after the interven-
Characteristic Group N=40
(Routine management) tion, compared to (52.5%) before intervention.
(Intervention )
Patients comments indicated that they felt comfort-
N % N %
able, relaxed, and believed that treatment could
Dyslipidaemia 25 62.5 25 62.5 relieve fatigue, numbness and cramps in their feet.
Diabetes Mellitus 30 75.0 29 72.5 p<0.05. Regarding the control group, all patients
Heart Disease 7 17.5 6 15.5 'comments before and after routine care indicated
no significant differences p>0.05 (Table 6).
Gout 11 27.5 12 30.0
Kidney 4 10.0 4 10.0 Post intervention results:
Stroke 2 5.0 3 7.5
There was a decrease in systolic blood pressure
of 23.7mmHg in the reflexology group compared
Top ten medical treatments of the two study with a decrease of 7.3mmHg in the control group.
groups: There was no difference in both groups There was a decrease in diastolic blood pressure
related to the top ten medical treatments and also of 14.5mmHg in the reflexology group compared
other treatments. Some participants had more than with a decrease of 3.7mmHg in the control group
one medical treatment, thus the total did not equal (Table 5).
100% (Table 4).
The findings showed that foot reflexology lower
Results of blood pressure and the quality of blood pressure in patients with hypertension, but
life: There was a statistically significant decrease it had little impact on the quality of life in these
in means of systolic blood pressure between pre patients (Table 5).
Karima Elshamy & Eman Elsafety 199

Table (4): Top ten medical treatments of the studied groups N=80.

Foot
Control
Reflexology
Group N=40
Medical treatments Group N=40
(Routine management)
(Intervention )

N % N %
Antihyperlypidaemic agents 25 62.5 24 60.0
Beta-blockers 16 40.5 19 47.5
ACE inhibitors 15 37.5 13 32.5
Diuretics 15 37.5 16 40.5
Anticoagulants, antithrombolytics & 14 35.0 11 27.5
fibrinolytics
Anti-anginal drugs 10 25.0 10 25.0
Antidiabetic drugs 10 25.0 9 22.5
Angiotensin II antagonists 5 12.5 6 15.0
Calcium antagonists 5 12.5 6 15.0
Other antihypertensive 2 5.0 3 7.5

Table (5): Pre and Post intervention results of blood pressure and the quality of life of the studied groups N=80.

Foot Reflexology Group Control Group

N=40 N=40
(Intervention ) (Routine management)
Pre Post Pre Post
intervention interventions p-value intervention interventions p-value
Mean SD Mean SD Mean SD Mean SD
Systolic blood pressure 160.2 2.6 136.5 2.0 162.5 2.5 155.2 2.4
Diastolic blood pressure 102.0 1.2 87.5 1.1 p<0.05 100.1 1.2 96.4 1.2 p>0.05
Quality of life:
Quality of life general score 3.8 0.1 3.9 0.1 p>0.05 3.6 0.1 3.7 0.1 p>0.05
Health satisfaction 3.3 0.1 3.4 0.1 3.1 0.1 3.3 0.1
Physical health 64.3 1.7 65.0 1.3 66.1 1.6 66.0 1.5
Psychological health 65.8 1.8 66.7 1.6 p>0.05 67.1 1.9 68.9 1.9 p>0.05
Social relationships 70.1 1.8 70.1 1.7 75.0 2.1 74.3 2.2
Environment 66.2 1.5 66.5 1.5 67.8 1.9 68.0 1.8

Table (6): Patients' comments of pre and post intervention of the two groups N=80.

Foot Reflexology Group Control Group

N=40 N=40
(Intervention ) (Routine management)
Pre Post Pre Post
intervention interventions p-value intervention interventions p-value
N % N % N % N %
Satisfaction:
Satisfied 21 52.5 30 75.0 19 47.5 15 37.5
Average 4 10.0 10 25.0 6 15.0 4 10.0
Not satisfied 15 37.5 4 10.0 p<0.05 15 37.5 14 35.0 p>0.05
Feel comfortable 10 25.0 19 47.5 8 20.0 8 20.0
Feel relaxed 10 25.0 18 45.0 9 22.5 10 25.0
Relieves fatigue, numbness, 5 12.5 11 27.5 6 15.0 8 20.0
cramps
200 Effect of Nursing Interventions Using Foot Reflexology on Blood Pressure
Discussion
Hypothesis one: There is a decrease in mean
blood pressure level between the foot reflexology
and control groups at the end of four weeks of
treatment. Analyses of data in this study indicated
that there was a statistically significant difference
in mean blood pressure between the foot reflexol-
ogy group and control group at the end of four
weeks of treatment. The mean diastolic blood
pressure in the foot reflexology group was statis-
tically significantly lower than in the control group
(p<0.05).
Frankel [35] explored the effects of foot reflex-
ology on the baroreceptor reflex, which controls
blood pressure. He found that baroreceptor reflex
sensitivity was significantly lowered in the inter-
vention groups (foot reflexology and foot massage),
compared with the control group. Baroreceptor
reflex sensitivity was measured using sinus arrhyth-
mia and phase IV of the Valsalva maneuver, a
period in the Valsalva maneuver during which
blood pressure is substantially raised above the
baseline. These blood pressure results are different
to those outlined by Frankel [35] who found that,
between foot reflexology and foot massage, there
was no significant difference in resting blood
pressure after intervention.
The results of our study supported the hypoth-
esis that foot reflexology decreases blood pressure
in patients with hypertension. In this study, the
results in relation to blood pressure are comparable
to those of Park and Cho [24] who found in their
research that there were no significant differences
in diastolic blood pressure and LDL cholesterol
between the foot reflexology group and the control
group (who received no intervention). In contrast
with this study, however, Park and Cho found that
systolic blood pressure and triglyceride levels
significantly decreased in their foot reflexology
group compared to their control group. In addition,
life satisfaction was significantly improved in the
foot reflexology group.
Compared to Park and Cho’s [24] study (2004),
our study was performed using a bigger sample
size and with control as a comparison intervention
(Park and Cho [24] , provided foot reflexology only
in a small group of 34 hypertensive patients-18 in
the foot reflexology group and 16 in the control
group who received no intervention). From both
studies, we can conclude that foot reflexology has
been proved to lower diastolic and systolic blood
pressure. However, its effects on quality of life or
life satisfaction in patients with hypertension are
ambiguous.
Our study showed that foot reflexology was
more likely to reduce diastolic and systolic blood
pressure than control group. Previous studies sup-
porting these results were a study by Hayes & Cox
[36] and another by Jirayingmongkol et al. [37] .
However, these two studies used different measure-
ment and foot massage procedures to test blood
pressure. Hayes and Cox [36] used mean arterial
blood pressure as an indicator of measurement of
physiological and psychological stress in patients
in a critical care unit. They found that there was
a significant decrease in heart rate, mean arterial
blood pressure and respirations during the foot
massage intervention in participants in the foot
massage group compared to those in the control
group who received no intervention. Jirayingmon-
gkol et al. [37] used Thai foot massage which is
quite different in style and procedure from the
current study to measure vital signs in older sub-
jects. They found that Thai foot massages signifi-
cantly decreased blood pressure, pulse rate and
respiratory rate in these people. Given the differ-
ences in measuring, procedures and samples, we
can not conclude that foot massage can lower blood
pressure in patients with hypertension.
Hypothesis two: There is an improvement in
mean quality of life between the foot reflexology
and control groups at the end of four weeks of
treatment p>0.05. Results from this study showed
no significant difference in mean quality of life
for both groups. These results differed markedly
from study results of Park & Cho [24] and Hodgson
[12] . Park & Cho [24] showed that foot reflexology
significantly improved life satisfaction in 34 pa-
tients with hypertension. This study did not support
Park and Cho’s [24] conclusions.
Similarly, Hodgson [12] found that foot reflex-
ology could improve quality of life. However,
Hodgson’s study was based on cancer patients and
is difficult therefore to compare with the effects
of foot reflexology on quality of life in patients
with hypertension. In addition, the sample size in
her study was small-only twelve subjects including
six in the foot reflexology group, and six in the
gentle foot massage group. Hodgson used the visual
analogue scales for cancer patients to measure
quality of life, as contrasted from the current study’s
use of the WHOQOLBREF World Health Organi-
zation [30] which is suitable for use with people
who have a general chronic disease. There is a
little difference in mean quality of life between
the foot reflexology and control groups at the end
of four weeks of treatment. The evidence relating
to foot reflexology, quality of life and patients with
hypertension did not indicate that foot reflexology
Karima Elshamy & Eman Elsafety
can improve quality of life in patients with hyper-
tension.
However, the results from open-ended question-
naire showed the benefits from these complemen-
tary therapies. These results could well reflect the
real benefits of foot reflexology and foot massage-
to help people feel more comfortable and relaxed,
and improve blood circulation in the feet. The
results are supported by a study by Long, Huntley
& Ernst [18] who surveyed 223 complementary/
alternative medicine organizations about the ben-
efits of complementary therapies, including reflex-
ology and massage. There was a 34% response
rate to their survey, and the results showed that
both reflexology and massage were suitable treat-
ments for relieving stress or anxiety, headaches or
migraines, and back pain.
Limitations of the study:
1- Setting: With limited space, the researchers were
unable to have a private room to carry out the
treatments. Treatments were provided in rooms
at the outpatient department where many pa-
tients came to see doctors. Sometimes it was
quite noisy. These factors might make it difficult
for participants to feel relaxed and therefore
achieve the desired effect.
2- The method of reflexology: This study used
Farnsworth’s method of foot reflexology-‘the
original western modern foot reflexology meth-
od’ Dougans [2] . Other studies may have used
different methods, e.g. the eastern foot reflex-
ology method from China, and achieved differ-
ent results.
3- Small sample sizes, very specific patient group,
limited justification for duration or type of
intervention, and/or untested outcome measures.
Replication with a larger sample of hypertensive
patients is necessary.
Conclusion and recommendations:
This study supported that foot reflexology can
reduce blood pressure levels in patients with hy-
pertension. Future research, which addresses the
limitations of this study, could continue the inves-
tigations of these claims. Studies are also needed
to compare reflexology with other complementary/
alternative therapies (e.g., massage, healing touch,
relaxation response), as well as its effect on lipid
profiles in hypertensive patients.
References
1- BYERS D.C.: Better health with foot reflexology, Ingham
Publishing Inc., Florida, 2001.
201
2- DOUGANS I.: Complete illustrated guide to reflexology,
Harper Collins Publishers, London, 2002.
3- Australian Institute of Health and Welfare: The relationship
between overweight, obesity and cardiovascular disease,
Australian Institute of Health and Welfare, Canberra,
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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e- ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 7, Issue 5 Ver. I (Sep.-Oct. 2018), PP 87-93
www.iosrjournals.org

“ A Study to assess the effectiveness of Back massage on Anxiety

level, Heart rate and Blood pressure among Hospitalized
Hypertensive patients at selected Hospitals Tumkur”.
1
.Dr. K. Ramu. M.SC (N), RN, RM .PhD , 2.Dr Yathi Kumar Swamy Gowda ,
3
. Dr.Bharathi M
Principal, RR College of Nursing Bangalore ,Prinicpal Alva s College of Nursing ,Moodibidri
Principal, Karnataka College of Nursing
Corresponding Author: Dr. K. Ramu

Abstract: Objective: To Assess the effectiveness of back massage on anxiety level, heart rate and blood
pressure among hospitalized hypertensive patients. Research Methodology: - Quasi experimental design with
120 hypertensive patients, 60 for experimental group and 60 for control group were allotted through purposive
sampling techniques. Results: - The results showed that back massage was highly effective in reducing anxiety
level, maintaining heart rate and reducing and maintaining blood pressure among hospitalized hypertensive
patients in experimental group than control group. There is a significant association between pretest and post
test scores of anxiety level, heart rate and blood pressure with the age, occupational status , annual income of
the family, duration of hospitalization of the hypertensive patients and no association among gender and marital
status .Conclusion: The study concluded that back massage is effective in reducing anxiety level, maintaining
heart rate and reducing and maintaining blood pressure.
----------------------------------------------------------------------------------------------------------------------------- ----------
Date of Submission: 28-08-2018 Date of acceptance: 11-09-2018
----------------------------------------------------------------------------------------------------------------------------- ----------

I. Introduction:
Hypertension has emerged as major health problem in India and in many developing countries.
Hypertension directly responsible for 57% of all stroke deaths and 24% of all cardiac heart diseases deaths in
India. About 50 million adults in the united states suffer from Hypertension. Hypertension is the most important
risk factor for cardio vascular and chronic renal failure disease 1. The prevalence of Hypertension in Indian
urban population has increased from 2- 4 % in mid 1950‟ s to 10-15% at the end of 20th century. In rural
population the prevalence increased from 1-2% to 4 to 8%. 2 Hypertension imposes high costs on both
individuals and society. In the united states, more than 10 billion dollars are spent on this disorder every year.
Onley etal suggested that complementary medicine in order to control blood pressure and stress.4 Osborn etal,
stated that use of complementary medicine could be effective in reducing blood pressure and this method was
easily available and more effective compared to medications. Considering the patho physiology of blood
pressure and the effective mechanism of massage therapy, relaxation through massage can facilitate the response
of parasympathetic nerve, thus reducing heart rate, blood pressure and anxiety. Aourell etal suggested that
repeated sensory stimulation during massage could result in neural changes and automatic system activity and
consequently could cause changes in blood pressure and heart rate.5

II. Need For Study

There is a strong correlation between changing life styles factors and an increased in hypertension in
India. Sedentary life style is a major cause of death and doubles the risk of cardiovascular diseases, diabetes
mellitus and obesity. Stress is considered to be one of the major predisposing factors of hypertension.2,3
The current concept for treatment of hypertension is the use of combination therapy of pharmacological
and non Pharmacological management. According to current concepts the holistic care for hypertension includes
complementary alternative medicine like relaxation technique, yoga, deep breathing exercises and massage
therapy. Among all, massage therapy is one of the fastest growing complementary and alternative medical
therapies.9 Massage can lower psycho emotional and somatic arousal such as anxiety and tension. As a
therapeutic modality, massage is being used for relief of pain, swelling, muscle sprain , tension and anxiety
associated with large number of disorders affecting muscular, nervous, cardiovascular and other system .3
According Watson (1989), massage like touch is a means of comforting some who is ill, helping to
relieve any unpleasant symptoms. The whole body can be relaxed by massaging the back or by rubbing back.

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 “ A Study to assess the effectiveness of Back massage on Anxiety level, Heart rate

The experience of illness and hospitalization often elicits a stress response which may manifest as increase heart
rate, increased systolic and diastolic blood pressure anxiety and general discomfort. The well established
nursing intervention, back rub or back massage has been utilized as a comfort measure for hospitalized
hypertensive patients.7,11
The overall aim of this study is to determine the effect of modest clinical practice of back massage on anxiety
level and heart rate of hospitalized hypertension patients Hence the investigator likes to implement the back
massage as an effective intervention for hospitalized hypertension patients and in turn practice in the clinical
settings as a vital nursing intervention. Investigator thinks that the nurses serve as an effective intervention for
the management of this “Silent Killer Disease”.

III. Statement Of The Problem

A study to assess the effectiveness of back massage on anxiety level. Heart rate and blood pressure
among Hospitalized Hypertensive Patients at selected hospitals Tumkur.

IV. Objectives
1) To assess level of anxiety, heart rate and blood pressure among hospitalized hypertensive patients in the
experimental group before and after back massage.
2) To assess the level of anxiety, heart rate and blood pressure among hospitalized hypertensive patients in the
control group before and after routine treatment.
3) To determine the effectiveness of back massage on anxiety level, heart rate and blood pressure among
hospitalized hypertensive patients.
4) To find out the association between the effectiveness of back massage on anxiety level, heart rate and blood
pressure among hypertensive patients with their selected demographic variables.

V. Research Methodology
Research Approach:
Evaluative research approach was used in this study.

Research Design: Quasi experimental design was used in this study.

Sample and Sampling Technique:

The Hypertensive patients who were admitted in both Govt. District Hospital and Shridevi Hospital
were selected by purposive sampling Technique. The subjects were selected for each group by simple random
technique and were allotted to experimental and control group until each group attains 60 sample.

Sample Size :
120 Hypertensive Patients who met the inclusion criteria, 60 for experimental group and 60 for control group.

Schematic Representation of Research Study.

Group Pretest On (Day one) Intervention Post Test on (7th day)

Experimental groups -Anxiety level Back Massage -Anxiety Level
-Heart Rate -Heart Level
-Blood Pressure -Blood Pressure
Control Group -Anxiety level No Intervention -Anxiety Level
-Heart Rate ( Routine Treatment) -Heart Level
-Blood Pressure -Blood Pressure

Criteria For Sample Selection

Inclusion Criteria
1) Hospitalized Hypertensive Patients.
2) Hypertensive Patients who are willing to participate in the study.
3) Both male and female hypertensive patients will be included in the study.

Exclusive Criteria
1) Hypertensive Patients who are not willing or not interested in the study.
2) Hypertensive Patients who are critically ill.

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 “ A Study to assess the effectiveness of Back massage on Anxiety level, Heart rate

Instruments Used For The Study:

Based on the objectives of the study a structured interview schedule with Modified State trait anxiety
scale and a table to record heart rate and blood pressure was prepared to assess the anxiety level and heart rate
among hospitalized hypertensive patients.

Development Of The Tool:

A Structured Interview Schedule was developed to assess the hospitalized hypertensive patients.
The instrument which were used to measure the dependent variables were:
Heart Rate measured by – Auscultation and palpation method.
Blood pressure by – Sphygmomanometer:- Auscultation and palpation method.

Descripiton Of Th E Tool:
The components of the instrument:-

Section I: - Interview schedule for the collection of Baseline information.

Age, gender, marital status, educational level, occupational status ,annual income of the family, diet of
the patients, duration of the hospitalizations, history of skin allergies and practice of relaxation techniques of
hypertensive patients.

Section II: - Modified Spiel Berger’s State Anxiety Inventory.

The standardized Spielberg State Trait Anxiety Inventory consists of totally 40 items, 20 items of
which are used to ascertain present anxiety levels ( A state) and other 20 items to measure general levels of
anxiety ( A trait ). First 20 items are only included in the scale.
Spiel Berger‟s state anxiety inventory was modified by the investigator according to the
administrability and convenience. It measures the state of anxiety of the hospitalized hypertensive patients.
Modified State anxiety scale consists of 20 closed ended dichotomous questions to assess anxiety level of
hospitalized hypertensive patients.
Scoring scale consists of two options “YES” or “NO”. There are 10 positive stated items and 10
Negative stated items. For the positive stated items score of “YES” is “1” and “NO” is “0”. In the Negative
stated items scores for “YES” is “0” and “NO” is “1”.Scores ranges from minimum of “0” and maximum “20”.
All scores were summed up for each individual samples. The anxiety level of hospitalized hypertensive patient
was arbititarly categorized as follows.
Severe Anxiety - 0-3.
Moderate Anxiety - 4-10.
Mild Anxiety - 11-15.
No Anxiety- - 16-20.

Section III:-A Table To Record The Physiological Parameters:-

A table to record the physiological parameters. Table was constructed to record Blood Pressure and
heart rate.
 Blood Pressure is measured with the Sphygmomanometer – Auscultation measure and Palpation
 Heart Rate – Palpation method
The Blood Pressure and Heart Rate were measured on the Ist day (pretest scores) at three intervals i.
e., 8am, 12pm , 4 pm and 7th day (post test scores) at same time interval as 1st day.

Testing Of The Instrument:-

a) Content Validity:
Minor modifications were made on the basis of recommended and suggestions of experts. After
consulting the experts final tool was edited by English language experts without changing the meaning of the
tool. It was found to be suitable for the hospitalized hypertensive patients.

b) Reliablity
Reliability of the tool was established by using Split Half technique which measures the Co-efficient
of internal consistency. The reliability of the Split half test was found by using Karl Pearson‟s Correlation
formula. Spearman‟s Brown Prophecy formula was used to find out the reliability of the full test.
R= 2r
1+r
R= Reliability of co efficient of co relation for whole test
r = reliability of co efficient of co relation for half test.

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 “ A Study to assess the effectiveness of Back massage on Anxiety level, Heart rate

The reliability co efficient correlation of Modified Spiel Berger‟s state anxiety inventory was found to be r=0.93.

Procedure For Data Collection :

A formal administrative permission was obtained to conduct the study from medical superintendent of
Govt. District Hospital Tumkur and Shriedevi Hospital Tumkur. Before collecting data, prior consent was
obtained from subjects. Samples were selected as per sampling criteria. The purpose of the study and co-
operation required from participants was explained to them. Confidentiality was assured. Consent to participate
in the study was obtained from each subject. A comfortable place was selected and participants were made
comfortable and relaxed.

Pretest:
Was conducted separately for both experimental and control group of hypertensive patients. Pretest
was conducted by face to face interview using modified state Anxiety inventory to check anxiety level. Heart
rate and blood pressure were recorded in table at three intervals that is at 8AM, 12PM and 4 PM.

Intervention:
(Implementation of therapeutic back massage) The back massage was administered to only
experimental group. The investigator followed nine basic steps of back massage. The investigator took
suggestions and practiced back massage under the guidance and supervision of trained physiotherapist. On the
second day onwards back massage was administered to the hypertensive patients at 3 intervals per day for 15
minutes till 6th day. After each session of back massage the patients were allowed to relax in a comfortable
position.

Post Test :
After administration of series of back massage from 2 nd to 6th day, post test was conducted on 7th day.
The post test was conducted for both experimental group and control group separately. The questionnaire used
in pretest was administered in the post test.

VI. Results of the Study. :

It is observed that most of the hypertension patients were in the age group of 50-60 years [36] 60% ,
above 60 years [13] were about 21.6% and the least number of 11 patients. (18. 3%) were in the age group of
40-50, in the experimental group. Whereas in control group majority of patients were in the age group of 50-60
years[32] 53%, least number in the age group 40-50 [10] 16% and 60 and above age group were 18 yrs. (30%)
Majority of hypertension patients in experimental group were female 43 (71%)and 17 were male (28%)
.In control group male were 32(53%) and female 28(46%).
With regard to education status of hypertensive patients were at collegiate level 23(38.3%), illiterate
were 9(15%) , primary education 18(30%) and high school education 10(16%) in experimental group and in
control group, illiterate were 15(25%), primary education 12(20%) , high school education 17(28%) and
collegiate education were 16(26.6%).
Distribution regarding marital status shows 33(55%) were married and 26(43%) were widower in
experimental group, where as in control group 38(63%) were married ,20 (33%) were widower and 2 were
single.(3.3%)
Occupational status shows that majority of samples were [27] agriculturists (45%) ,16 were laborers (
26%),7 were employed (11.6%) and 10(16%) were dependent in experimental group. In control group 15(25%)
were employed, 20(33.3%) were agriculturist, 12 (20%) were dependent and 13 were laborers.(33.33%)
It is observed that 41samples had annual income of Rs 4001 and above, (68%), 8
(13.33%) 2000-3000 annual income and 11 had Rs 3001-4000 annual income (18.33%) in
experimental group, where as in control group 35 samples had Rs 4001 and above income (58.3%), 12 had Rs
2000-3000 income(20%) and 13 had Rs 3001-4000 annual income (21.2%).
Majority were [39] non vegetarians (65%), 21 were vegetarians (35%) in experimental group whereas
in control group 32 were non vegetarians (53.3%) and 28 were vegetarians(46.66%).
Distribution regarding the duration of hospitalization in experimental group shows that 30 hypertensive
patients (50%) stayed in hospital between 5 to 10 days , less than 5 days (10%) only 6 samples, 6 patients stayed
between 10 to 15 days (10%), 10 patients between 15 to 20 days (16%) stayed in hospital. In control group 20
patients(33%) stayed in hospital between 5 to 10 days, 15 were(25%) less than 5 days, 8 were (13.3%) between
10 to 15 days ,10 were (16%) between 15 to 20 days and 7 were (11.6%) stayed in hospital 20 days and above .
It was observed that majority of patients were free from any type of skin infections in both
experimental and control group. Majority of hypertensive patients does not practice any relaxation techniques

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 “ A Study to assess the effectiveness of Back massage on Anxiety level, Heart rate

(95%), only 3 (5%) patients practiced relaxation techniques like yogs and meditation in experimental group and
in control group only 5 patients (8.3%) practiced relaxation techniques..

Analysis of effectiveness of back massage on.

Anxiety Level
In order to find the mean difference between pretest and post test anxiety scores paired „t‟ test was computed. In
experimental group, the mean pretest score is 8.45, SD 2.26 and mean post test score 16.95, S D 1.57, P value <
0.001. The calculated t value is less then calculated table value, hence accept the alternative hypothesis. It is
highly significant at 0.001 level, this indicates that the back massage was highly effective in reducing anxiety
level of subjects in Experimental Group.
In Control Group, the mean pretest was 8-12, SD 2-18 and mean posttest score 9.16. It indicates that, there
was significant difference between pretest & psot test anxiety level score in Control Group.
a) Heart Rate : In Experimental Group the mean pre test score of heart rate is 80.77, SD 5.37 and the post
test score is 78.93, SD 4.06 the „t‟ value is 2.02, p=0.031. By this above result it can be stated that back
massage was significantly effective in maintaining heart rate of hospitalized hypertensive patients. The
mean pretest score of heart rate 79.0, SD 4.30 and the mean post test score is 78.20. SD 4.01, K value is
4.0, P is 0.124,it shows that there was minor significant reference between pretest and post test score in
control group.

b) Blood Pressure :
In experimental group the mean pretest score of systolic pressure in 152.8, SD is 4.7, „t‟ value is 19.23, PL
0.001. Hence the statistical data shows the effect of back massage on systolic data shows the effect of back
massage on systolic blood pressure is highly significally in Experimental Group the mean pretest score of
diastolic pressure is 90.0, SD 5.7, after back massage the post test score is 82.9, SD 4.7, „t‟ value is 10.18,
PL 0.001. Hence the statistical data shown that effect of back massage on diastolic blood pressure is highly
significant. Where as in control group mean pretest score of systolic blood pressure is 146-2, SD11.4, and
the post test score is 142.2, SD is 9.9 „t‟ value 20.47, P is 0.024 and it as significant .

In Control Group the mean pretest score of diastolic blood pressure is 85.1, SD is 4.33 and pos test score is
80.2 SD is 4.10 t value is 9.2 is M 0.087 and is the highly significally .

3. Association between pretest score of anxiety level, heart rate, blood

pressure and socio demographic variable in experimental group.

The chisquare value of demographic variables show that the gender, marital status, diet and history of skin
allergies are not significant where as age, educational status, occupation status, annual income of family,
duration of hospitalization and relaxation techniques, are associated with the pretest level of knowledge.
Association between posttest scores of anxiety levels, heart rate, blood pressure and socio demographic
variables in experimental group.

The chi square value of demographic variables shows that gender, marital status, diet and history of skin
allergies are not associated where as age , educational status , occupational status, annual income of the family,
duration of hospitalization and relaxation techniques are associated uses post test knowledge.

Association between pretest score of anxiety level, heart rate, blood pressure and socio demographic
variables in control group.

The Chi square value of demographic variable shows that age and relaxation technique are not associated where
as gender, marital status , educational status occupational status, annual income of the family , duration of
hospitalization, history of skin allergies are associated the pretest knowledge.

Association between post test score of anxiety levels heart rate blood pressure and socio demographic
variables in control group.

The Chi Square value of demographic variables shows that age is into associated with post test knowledge.
Where as gender, marital status , educational status, occupational status , annual income of the family, diet,
duration of hospitalization , history of skin, allergies and relaxation techniques are associated with post test
knowledge.

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 “ A Study to assess the effectiveness of Back massage on Anxiety level, Heart rate

Implications
The findings of the study have brought for the certain that certain that have for reaching implications for
nursing in the area of practice education, administration, research and community.
1]Nursing Practice : Nurses play an important role in the management of hypertensive patients by non
pharmacological therapies in the daily routines in the clinical. The nurses have to understand the importance
and use of back massage therapy as a form of relaxation among hypertensive patients.
2) Nursing Education: The nursing curriculum has to emphasize more on non pharmacological methods in
chronic diseases especially hypertension.
3) Nursing administration: A hospital policy should be adopted to provide back massage or written
information to all inpatients & outpatients. The nurse administrator should take initiative in organizing
continuing educational programmers on message therapy for nursing personal in hospital and community
settings to gain knowledge and management of hypertension through non pharmacological therapies as the back
massage.
4) Community: Each member of health team has the responsibility to educate the general public. Health care
providers have to oriente This global epidemic and important of back massage in hypertension.

VII. Conclusion
The study was conducted to findout the efficacy of back massage on anxiety level heart rate and blood pressure
among hospitalized hypertensive patients.

The following conclusions were drawn based on the finding of study.

1) The majority of the subjects in Experimental Group were 60% aged between 50-60 years and in Control
Group 53% aged between 50-60 years.
2) Majority of subjects were females 71%
3) 15% of subjects were illiterate, 30% had primary education
4) 45% of subjects were farmers, only 11% were employed, 26% were laboring and 68% of subjects had more
than Rs. 4000/- annual income and only 13% had Rs. 2000, 3000 annual income.
5) Majority 65% of subjects were non-veg.
6) Majority 50% of subjects stayed at hospital for about 5 to 10 days only 1% of subject had skin infection and
99% had no skin infections.
7) 95% of subjects not practicing relaxation techniques.
8) In Experimental Group, Post test score [ 16.95] higher than pre test score
( 8.45) it is highly significant at 0.001 level, this indicates that back massage was highly effective in
reducing anxiety leave among hospitalized hypertensive patients.
9) The pretest score of Heart Rate is 80.77 and post test score is 78.93. It shows back massage was
significantly effective in maintain hear rate of hospitalized patients.
10) The pretest score of systolic blood pressure is 152.8 and after back massage therapy mean post test score
was 126.5 where as diastolic pressure pretest score was 90.9 and back massage mean port test was 82.9.
The result showed that back massage was very effective in reducing & maintaining Blood Pressure among
hospitalized hypertensive patients..
11) In Control group there was short significant difference between pretest scores and post score of anxiety
level, heart rate & blood Pressure.
12) There is a significant association between pretest scores & past test scores of anxiety level, Heart Rate &
Blood Pressure. with age, of the patients.
13) There is a significant association between pretest scores and post test score and occupational status
educational status annual income of the family, duration of hospitalization of the Hypertensive patients.
14) There is no signification associations between pretest score and post test sizes and gender and marital
status.

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Dr. K. Ramu “A Study to assess the effectiveness of Back massage on Anxiety level, Heart
rate and Blood pressure among Hospitalized Hypertensive patients at selected Hospitals
Tumkur ”.” IOSR Journal of Nursing and Health Science (IOSR-JNHS) , vol. 7, no.5 , 2018,
pp. 87-93.

DOI: 10.9790/1959-0705018793 www.iosrjournals.org 93 | Page