Effects of Reflexotherapy on Acute Postoperative Pain and Anxiety Among Patients With Digestive Cancer

Transcription

1 Copyright B 2008 Wolters Kluwer Health Lippicott Williams & Wilkis Shiow-Lua Tsay, PhD, RN Hsiao-Lig Che, MS, RN Su-Chiu Che, MS, RN Hug-Ru Li, PhD, RN Kua-Chia Li, PhD Effects of Reflexotherapy o Acute Postoperative Pai ad Axiety Amog Patiets With Digestive Cacer K E Y W O R D S Axiety Digestive cacer Postoperative pai Reflexotherapy Eve after receivig aalgesia, patiets with gastric ad liver cacer still report moderate levels of postoperative pai. The purpose of the study was to ivestigate the efficacy of foot reflexotherapy as adjuvat therapy i relievig pai ad axiety i postoperative patiets with gastric cacer ad hepatocellular cacer. The study desig was a radomized cotrolled trial. Data were collected from 4 surgical wards of a medical ceter i 2005 i Taipei, Taiwa. Sixty-oe patiets who had received surgery for gastric cacer or hepatocellular carcioma were radomly allocated to a itervetio ( = 30) or cotrol ( = 31) group. Patiets i the itervetio group received the usual pai maagemet plus 20 miutes of foot reflexotherapy durig postoperative days 2, 3, ad 4. Patiets i the cotrol group received usual pai maagemet. Outcome measures icluded the short-form McGill Pai Questioaire, visual aalog scale for pai, summary of the pai medicatios cosumed, ad the Hospital Axiety ad Depressio Scale. Results demostrated that studied patiets reported moderately high levels of pai ad axiety postoperatively while patiets were maaged with patiet-cotrolled aalgesia. Usig geeralized estimatio equatios ad cotrollig for cofoudig variables, less pai (P G.05) ad axiety (P G.05) over time were reported by the itervetio group compared with the cotrol group. I additio, patiets i the itervetio group received sigificatly less opioid aalgesics tha the cotrol group (P G.05). Fidigs from this study provide urses with a additioal treatmet to offer postoperative digestive cacer patiets. Authors Affiliatios: Graduate Istitute of Nursig, Natioal Taipei College of Nursig (Dr Tsay); Taipei Geeral Vetera Hospital (Ms Che); ad the Natioal Taipei College of Nursig (Ms Che ad Drs H. R. Li ad K. C. Li), Taipei, Taiwa. Correspodig author: Shiow-Lua Tsay, PhD, RN, 365 Mig Te Rd, Pei-Tou 112, Natioal Taipei College of Nursig, Taipei, Taiwa (sltsay@ mail1.tc.edu.tw). Accepted for publicatio August 22, Reflexotherapy for Acute Postoperative Pai ad Axiety Cacer Nursig TM, Vol. 31, No. 2,

2 Cacer has bee the leadig cause of death i Taiwa for the last 2 decades. 1 Amog all types of cacers, cacer of the digestive system occurs most frequetly. Patiets with cacers such as hepatocellular carcioma or gastric cacer ofte have to receive major abdomial surgery as a treatmet modality. Thus, maagemet of postoperative symptoms becomes a essetial part of ursig care. Despite this, postoperative pai maagemet remais oe of the major challeges i the care of surgical patiets. The uderstadig of acute pai physiology has advaced, ad ew methods of pai maagemet have emerged. Although care has improved, studies still show that postoperative pai cotiues to be iadequately treated, ad those patiets still experiece moderate to severe pai after surgery. 2Y4 I additio, patiets ofte experiece axiety that is commoly associated with pai. Acute postoperative pai ad axiety affect postsurgery recovery, resultig i more complicatios, loger hospital stays, greater disability, ad potetially chroic pai. 4 Although Wester medicie is still a maistream for patiets with postoperative pai, complimetary ad alterative therapies that could help i promotig comfort are recetly begiig to gai acceptace by practitioers. Sice 1997, the US Natioal Istitutes of Health 5 issued a report ackowledgig that alterative ad complimetary therapies could alleviate some side effects of treatmet, such as pai. Reflexology is oe of the most popular forms of alterative ad complemetary therapy which, whe itegrated with pharmacological treatmet, may be valuable i the maagemet of acute postoperative pai. However, there are cocers regardig the use of such therapy whe their effectiveess has ot bee clearly demostrated. Furthermore, little iformatio is available o the effect of reflexotherapy i postoperative pai of cacer patiets. 6,7 Therefore, the purpose of this study was to determie the effects of foot reflexotherapy as a adjuvat therapy o acute postoperative pai ad axiety amog patiets with digestive cacer. Reflexology is a maual techique based o the zoe theory that reflex poits o the feet correspod to orgas, glads, ad parts of the body. These poits are liked to iteral orgas ad structures by eergy chaels, zoes, ad/ or meridias. 7 Whe illesses or imbalaces occur i the body, cosequet eergy chaels become blocked. Reflexology massage is used to ope up these blockages, thus allowig eergy to flow freely agai, restorig the body s atural balace ad health. 7 Based o the euromatrix theory of pai, 8 reflexotherapy is also thought to relieve pai by trasmittig afferet impulses ad close the eural gates i the dorsal hor of the spial cord, thus blockig pai trasmissio. 6 The techique of reflexology is simple, ca be performed aywhere, requires o special equipmet, is oivasive, ad does ot iterfere with other treatmets a patiet may be receivig. 9 There is scat research o the effects of foot reflexology for postoperative patiets. However, the effects of foot massage were examied i 3 studies. For these studies, massage was defied as a form of touch or maipulatio performed o the soft tissue. First, a sample of 59 wome who uderwet laparoscopic sterilizatio was radomly allocated to 2 groups. The itervetio group received a foot massage ad aalgesia, whereas the cotrol group received oly aalgesia. At baselie, there were o differeces i the pai experieced by the 2 groups after surgery. The itervetio group reported less pai tha the cotrol group. 10 Yet, the pai level reported i this populatio was relatively low. I aother study, had ad feet massage was admiistered to 1 group of 18 patiets who uderwet gyecological, gastroitestial, urological, head ad eck, ad plastic surgery. These patiets reported a decrease i pai itesity ad distress. 7 I the last study, foot massage was give to 25 patiets after cardiac surgery. No sigificat differeces i pai ad psychological variables were foud betwee itervetio ad cotrol groups. 11 The research o foot massage is scat, ad the study desigs lack rigor. The effect of foot reflexology i cacer patiets was ivestigated. Patiets with breast ad lug cacer received 15 miutes of foot reflexotherapy. Reflexology was foud to alleviate axiety ad pai immediately for 23 patiets. 9 I aother study, the effects of foot reflexology i 36 hospitalized patiets with metastatic cacer were ivestigated. 12 Results of 2 sessios of reflexotherapy over 2 days resulted i a reductio of pai ad ausea. 13,14 There was o effect o pai after 3 hours or 24 hours of itervetio. Cosequetly, 10 miutes of foot massage admiistered to hospitalized cacer patiets resulted i immediate effects o perceived pai ad ausea. I coclusio, foot reflexology is a easy, oivasive, ad opharmacological therapy. Although the effectiveess of foot reflexology has bee studied i medical populatios, oly a study was aimed at postoperative cacer patiets. Furthermore, these study results were limited i geeralizability because of methodological issues. I additio, there are o studies that support the effects of foot reflexotherapy i acute postoperative pai of digestive cacer patiets. The specific aims of this study were to develop a reflexotherapy protocol ad to ivestigate the efficacy of foot reflexotherapy for alleviatio of pai ad axiety i patiets with cacer udergoig major abdomial surgery. The research questios were as follows: 1. What are the effects of foot reflexology o pai ad axiety i patiets who have udergoe surgery for digestive cacer as compared with a cotrol group? 2. What is the differece i pai medicatio cosumptio postoperatively betwee itervetio (arcotic aalgesia ad foot reflexology) ad cotrol groups (arcotic aalgesia) of patiets with digestive cacer? Methods Study Desig This study is a double-blid, radomized, cotrolled trial. Study participats were radomly allocated to the foot reflexotherapy group or cotrol group. A stratified block 110 Cacer Nursig TM, Vol. 31, No. 2, 2008 Shiow-Lua et al

3 radomizatio procedure was used, with stratificatio for the diagosis of gastric cacer or liver cacer. The radom umbers were computer geerated, ad slips bearig the allocated group were placed i evelopes that were serially umbered, sealed, ad opaque. Subjects i the itervetio group received 10 miutes of foot reflexotherapy o each foot for a total of 20 miutes oce per day for 3 cosecutive days o the same time i the eveig by a certified urse reflexologist. Subjects i the cotrol group received routie care. The itervetio was iitiated durig the secod day i cosideratio of patiets who were wakig up from surgical aesthesia ad more willig to accept the itervetio. Patiets were off the patiet-cotrolled aalgesia (PCA) o the morig of the fourth day postoperatively ad received as eeded itraveous ijectios of meperidie (Demerol) for pai. Pai medicatio was recorded durig the study. Sample ad Settig A sample of 62 postoperative gastric ad liver cacer patiets i 4 wards of a major medical ceter i the orther Taiwa was erolled over a 10-moth study period i All patiets who met the followig iclusio criteria were ivited to participate i this study period: 18 years or older, had major abdomial surgery for maily hepatocellular cacer ad gastric cacer i the 24 hours prior, alert, awake, i a stable medical coditio, able to verbally commuicate, received geeral aesthetics, ad used PCAs for pai. Exclusio criteria were history of chroic pai, dissemiated cacer, arcotic or ethaol addictio, peripheral europathy, foot amputatio, diagosed deep vei thrombosis, ope woud o foot, demetia, or psychiatric diagoses. Itervetio A itervetio protocol was developed by followig Fr Josef Eugster s foot reflexology maual which is based o the origial Igham method. 15 The protocol was reviewed by 3 reflexology experts ad revised accordigly. The fial protocol was used i a small pilot study ad was further revised. A urse therapist certified as a reflexologist provided foot reflexotherapy to all patiets i the itervetio group. Before the therapy, the feet were assessed to esure that there were o cotradictios to massage such as ulcer or edema. Each patiet was assisted to a comfortable positio. The foot reflexology was iitiated durig the eveig o postoperative day 2 while patiets are o PCA ad betwee 1 ad 3 hours after a dose of pai medicatio. The itervetio of reflexotherapy is based o the previous fidig which suggested that a 20-miute massage may produce beeficial results. 10 Durig the itervetio, the therapist used her thumb ad forefigers to apply pressures ad massage to each reflex zoe twice iitially. For the purpose of this study, digestive reflex zoes of upper ad lower abdome, liver, splee, gall bladder, duodeal, itestie, ad colo are massaged 5 times or more as suggested by experts. The techiques of keadig, frictio, rubbig, ad p2trissage were applied as recommeded by Fr Josef Eugster. 15 Data Collectio Demographic data, surgical data, ad history of aalgesic cosumptio were collected from the patiets chart. Visual aalog scale (VAS) for pai was collected daily from baselie, durig the itervetio, ad at follow-up. Data of the McGill Pai Questioaire (MPQ) ad the Hospital Axiety Scale were collected at baselie ad posttest (postoperative day 5) oly. Data were collected by a traied research assistat who was blided to radomizatio. I additio, VAS for pai was collected before ad after each sessio of reflexotherapy. Istrumets Pai was assessed with the short-form MPQ (SF-MPQ). 16 The SF-MPQ cosists of a pai descriptor ad a VAS for pai. The descriptor describes 15 differet types of pai rated by the respodet as 0 (oe), 1 (mild), 2 (moderate), ad 3 (severe). The 11 descriptors represet the sesory dimesios, whereas others represet the affective dimesios. The SF- MPQ correlates highly with scores of origial MPQ. The Chiese versio of SF-MPQ was used. Crobach " for the SF-MPQ was.78. Visual aalog scale for pai cosists of a 100-mm lie with ed poits of 0, idicatig o pai, ad 100, sigifyig the worst thikable pai. Scores are obtaied by coutig the umber of millimeters from 0 to the pai mark made by each participat. Visual aalog scale has bee reported as the most sesitive, valid, ad reliable method for measurig pai itesity. 16,17 Axiety was measured with the axiety subscale of the Hospital Axiety ad Depressio Scale (HADS). 18 The HADS is a reliable istrumet for screeig cliically sigificat axiety ad depressio. It has also bee show to be a valid measure of the severity of disorders of mood. Scores o the HADS subscales rage from 0 to 21, with higher scores idicatig more axious or depressed mood. Scores of 8 to 10 idicate possible cases of axiety, ad scores of 11 or more are proposed by the authors of the scale to idicate defiite cases. 18 Crobach " was.72. Power Aalysis The sample size was determied after data collectio of a pilot study of 10 patiets. A sample of 48 was proposed based o the sample sizes eeded for a power of 80%, effect size of 0.35, ad " =.05 as recommeded by Steves. 19(p511) Asampleof24 would be eeded per group; a total sample of 48 will be sufficiet for this study. However, 25% attritio rates could be expected; therefore, 62 subjects were estimated for this study. Ethical Cosideratios Approvals from the college ad the hospital research ad ethics committees were obtaied before iitiatio of the Reflexotherapy for Acute Postoperative Pai ad Axiety Cacer Nursig TM, Vol. 31, No. 2,

4 study. Potetial patiets were approached ad fully iformed of the purpose of the research, its methods, beefits, ad risks. Patiets gave writte coset oce they agreed to participate. Aoymity ad cofidetiality were esured, ad participats could withdraw from the study at ay poit without affectig their subsequet treatmet. Data Aalysis All statistical aalyses were carried out usig the SAS statistical package (SAS Ic, Cary, North Carolia). A geeral liear model was used to model the outcome (pai ad axiety) as a fuctio of mai effect (group differece) ad the covariates, icludig age, sex, ad types of cacer. Both the stability aalysis ad the aalysis of repeated relatioships were performed by geeralized estimatio equatios (GEE). A iteractio term (group differece time) was added ito each model to ivestigate the syergistic effect of reflexotherapy with time. Geeralized estimatio equatio was chose because cliical repeated data frequetly have a oormal distributio, ad the variaces ofte caot be assumed to be equal, as required of a aalysis of variace model. 20 Results Sample A total of 62 participats erolled i the study; each group cosisted of 31 patiets. Durig the study period, 1 patiet from the cotrol group dropped out because of postoperative complicatios. The fial sample icluded 31 hepatocellular cacer ad 30 gastric cacer patiets; 29 (47.54%) were males, ad 32 (52.46%) were females, with a average age of 59.8 years (SD, years). Forty-seve (77%) of them were married. More tha half of the participats had more tha a high school educatio ( = 32, 52.4%). Gastric cacer patiets had a surgical procedure of total ( = 3, 10%) or subtotal ( = 27, 90%) gastrectomy, whereas liver cacer patiets had a lobectomy ( = 14, 45.16%) or segmetectomy ( = 17, 54.84%). No sigificat differeces existed betwee the itervetio ad group at baselie with regard to demographics, disease, or treatmet variables (P 9.05). Chages i Pai Perceptio Over Time Effects of reflexotherapy o postoperative pai were measured by assessig the MPQ, daily VAS for pai, ad arcotic aalgesia cosumptio. The descriptive data of these variables are preseted i Table 1. At baselie, the mea MPQ scores for the itervetio group were (SD, 5.93) ad (SD, 4.60) for the cotrol group. There were o statistically sigificat differeces betwee the groups (t = 0.25, P =.80). The chages i mea pai perceptio for both groups declied from baselie to posttest at postoperative day 5 (Figure 1). Usig GEE, after cotrollig for potetial cofoudig variables, for the MPQ, the GEE results demostrated o group effects (P 9.05). Coversely, a iteractio term (group differece time) was statistically sigificat (j3.17, P =.02), idicatig that patiets who received reflexotherapy had less pai compared with cotrol group patiets over time (Table 2). The time-depedet chages, which were also statistically sigificat idicated that perceived pai for the itervetio group decreased by a additioal 3.70 poits (P G.0001). I additio, older patiets geerally had higher perceived pai score whe compared with youger patiets pai score (0.07 poits per year of age, P =.01). No differeces were foud with regard to sex ad types of diagosis betwee the groups over time (P 9.05). At baselie, the mea VAS pai score for the itervetio group was (SD, 19.95) as compared with (SD, 17.15) for the cotrol group (t = 0.61, P =.54). Participats had moderate levels of pai postoperatively eve uder PCA. Variables Table 1 & Cliical Variables for Itervetio ad Cotrol Groups (mea, SD) ( = 61) Itervetio ( = 30) Cotrol ( = 31) Mea SD Mea SD McGill Pai Scale Baselie Posttest VAS for pai Baselie (day 2) Postop day Postop day Postop day Postop day Axiety Baselie Posttest Demerol used (mg) Abbreviatio: VAS, visual aalog scale. t P 112 Cacer Nursig TM, Vol. 31, No. 2, 2008 Shiow-Lua et al

5 Figure 1 Chages i perceived pai (MPQ) ad axiety over time at baselie (postoperative day 2), ad follow-up (postoperative day 5). The data are show as meas T SEM (error bars). MPQ idicates McGill Pai Questioaire. For those i the itervetio group, VAS pai declied o postoperative day 3 (first day of reflexotherapy), but the pai icreased o day 4 ad desceded to a lower value at day 5 (the last day of reflexotherapy) ad remaied o the same level of pai o day 6 (follow-up). I cotrast, for those i the cotrol group, pai icreased over time throughout the follow-up period. Both groups of patiets reported more pai o the fourth day postoperatively. Geeralized estimatio equatio results demostrate that chages for mea VAS pai were statistically sigificatly lower i the itervetio group (j21.22, P G.0001) tha those i the cotrol group. The time-depedet chages were also a statistically sigificat idicatio that values for the itervetio group decreased by a additioal 2.42 poits daily (P =.010). Furthermore, a iteractio term (group differece time) was also oted, revealig that patiets receivig reflexotherapy had further decreased pai over time (j2.41, P =.029). Older patiets had higher VAS pai (0.24 per year, P =.0003). No differeces i pai over time were evidet with sex (P =.77) ad cacer type (P =.97) (Figure 2). Visual aalog scale for pai was also collected before ad immediately after each sessio of reflexotherapy for the itervetio group. The preitervetio mea pai score for reflexotherapy sessio 1 was mm (SD, mm), which decreased to mm (t = 3.958, P G.001) immediately after therapy, resultig i a mea differece of mm (SD, mm). Similarly, the mea pai score for therapy sessio 2 decreased 9.97 mm, from mm (SD, mm) to mm (SD, mm) (t = 5.97, P G.001). Agai, the mea pai score for therapy sessio 3 decreased mm from mm (SD, mm) to mm (SD, mm) (t = 4.52, P G.001). Thus, pai levels reported by patiets decreased sigificatly durig reflexotherapy. Participats were o a routie pai maagemet program, where patiets could request for arcotic aalgesia if eeded. The itervetio group used, o average, mg Demerol, whereas the cotrol group used, o average, mg. A t test revealed a sigificat differece betwee groups (t = 2.52, P =.015). Patiets i the reflexotherapy group received sigificatly less opioid aalgesics tha the cotrol group. Chages i Perceived Axiety Level of axiety at baselie was (SD, 2.57) for the itervetio group ad (SD, 3.10) for the cotrol group; patiets had moderately high levels of axiety after surgery. There was o statistically sigificat differece betwee groups at baselie (t = 1.11, P =.27). Both groups axiety levels decreased from postoperative day 2 to day 5. The GEE results demostrate o statistically sigificat variatios withi the itervetio group compared with the cotrol group (P 9.05). Time-depedet chages were statistically sigificat ad idicated that axiety i the itervetio group decreased by 1.37 (P G.0001) over time. Moreover, a iteractio term (group differece time) was also oted, revealig that patiets receivig reflexotherapy had further decreased perceived axiety over time (j1.12, P =.023). Patiets with gastric cacer geerally were more axious tha patiets with liver cacer (j1.37, P =.023). No Table 2 & Geeralized Liear Model a o the Effect of Pai for Reflexotherapy ( = 61) MPQ Pai VAS Pai Variable $ SE P $ SE P Group (itervetio vs cotrol) j j G.0001 Time j G.0001 j Time group (itervetio vs cotrol) j j Sex (male vs female) j Age (y) Cacer type (gastric vs liver) j Abbreviatios: $, coefficiet of modelig; MPQ, McGill Pai Questioaire; VAS, visual aalog scale. a Usig GEEs (geeralized estimatio equatios) for repeated measuremets ad the correlatio structure exchageable. Reflexotherapy for Acute Postoperative Pai ad Axiety Cacer Nursig TM, Vol. 31, No. 2,

6 Figure 2 Chages i VAS pai over time at baselie (postoperative day 2) ad durig reflexotherapy (postoperative days 3-5) ad follow-up (postoperative day 6). The data are show as meas T SEM (error bars). VAS idicates visual aalog scale. differeces i sex ad age were foud over time (P 9.05) (Table 3). Discussio We were surprised to fid that levels of perceived pai were moderately high postoperatively eve with PCA used by our study participats. These results, alog with those of similar studies, idicate that acute postoperative pai cotiues to be iadequately treated. 2Y4 We also discovered that perceived pai is highly correlated with axiety (r =0.43,P =.001) i this populatio; cosequetly, itervetios coupled with pharmacological maagemet to decrease perceptios of pai ad axiety postoperatively become essetial i this populatio. Our data revealed that patiets with gastric ad liver cacers i the reflexotherapy group experieced a statistically sigificat improvemet i perceived pai ad axiety postoperatively as compared with those i the cotrol group. Although the mechaism of foot reflexology o acute postoperative pai has ot yet bee well established, reflexology therapy might adjust ay imbalace that is apparet i the feet as reflected i the body orgas or structure. This the produces a reflex respose withi the correspodig area of body which allows healig processes to take place ad promotig comfort. 21 From the view of euromatrix theory, reflexotherapy may modulate the pai experiece by alterig the patter-geeratig matrix where the brai, eurotrasmitters, ad hormoes cotribute to pai suppressio ad release of edogeous opiates. 22 I additio, foot reflexology may also stimulate the opaiful erve fibers, resultig i pai ihibitio. 7,23 The study results demostrated that oivasive foot reflexology reduced the perceived pai ad axiety postoperatively amog digestive cacer patiets; o previous study has tested foot reflexology i hospitalized surgical patiets. Reflexology studies coducted with osurgical cacer patiets have show that this treatmet might improve pai ad axiety. 9,12,14 Our study adds empirical support for the effectiveess of reflexotherapy i gastric ad liver cacer populatios. Although the fidig of this study may be cosidered geeralizable i relatio to the desig, the sample size remais relatively small so as to geeralize to all cacer patiets. Our study foud that the patiets i the reflexotherapy group cosumed a sigificatly less amout of as-eeded arcotic aalgesia as compared with patiets i the cotrol group. Previous studies that ivestigated the effects of foot reflexology i pai coditios rarely documeted arcotic aalgesia cosumptio; thus, our study cotributes to the iitial evidece of reflexology i alleviatig pai. However, all of our patiets were o the PCA from the day of surgery to day 4 postoperatively. We were uable to aalyze the data o the amout of arcotic aalgesia cosumed durig the period of PCA; therefore, iterpretatios of our fidigs are limited. This study provides a foudatio for future studies of reflexology therapy i maagig acute postoperative pai ad axiety i patiets with gastric ad liver cacers. Future research studies could iclude replicatio ad expasio of the curret study ad iclude a larger sample usig a logitudial desig. Aother study will be coducted to better uderstad the short- ad log-term outcomes of reflexology. The study took place i 4 surgical wards of a medical ceter; cautio should be take whe geeralizig to other settigs. Future studies could be replicated i differet populatios to improve the geeralizability of the fidigs. Coclusios/Implicatios Nurses are i a positio to cosider the offerig of foot reflexology as oe optio i the maagemet of acute postoperative pai. The techique of foot reflexology is simple ad oivasive. The techiques ca be easily leared ad applied i cliical settigs. Followig this study, we traied surgical care urses, ad they ow implemet reflexotherapy i carig for surgical patiets with digestive cacer. Furthermore, we offered foot reflexology workshops ad traied patiets, families, ad healthcare professioals. They have reported positive ad promisig results. Variable Table 3 & Geeralized Liear Model a o the Effect of Axiety for Reflexotherapy Axiety $ SE P Group (itervetio vs cotrol) Time j G.0001 Time group (itervetio vs j cotrol) Sex (male vs female) j Age (y) j Cacer type (gastric vs liver) j Abbreviatio: $, coefficiet of modelig. a Usig GEEs (geeralized estimatio equatios) for repeated measuremets ad the correlatio structure exchageable. 114 Cacer Nursig TM, Vol. 31, No. 2, 2008 Shiow-Lua et al

7 I coclusio, our results suggest that reflexotherapy might effectively decrease perceived pai ad axiety postoperatively whe complemeted with pharmacological pai therapy i patiets with gastric ad liver cacers. The study provides a research-based itervetio for cliicias carig for patiets with digestive cacer. The applicatio of these fidigs might have importat implicatios for patiets with high levels of perceived pai ad axiety postoperatively. Assessmet of pai ad axiety levels of these patiets should be a essetial part of ursig practice, ad cliicias might wat to cosider providig foot reflexology as a method for improvig symptoms of pai ad axiety. ACKNOWLEDGMENTS The authors thak those patiets who participated i this study ad Dr Basia L. Belza of the School of Nursig, Uiversity of Washigto, for reviewig ad editig the mauscript. Refereces 1. Departmet of Health. Cause of death statistics. doh.gov. tw/en/webpage/idex. Accessed April 8, Coll AM, Amee JR, Moseley LG. Reported pai after day surgery: a critical literature review. J Adv Nurs. 2004;46(1):53Y MacLella K. Postoperative pai: strategy for improvig patiet experieces. J Adv Nurs. 2004;46(2):179Y Watt-Watso JH, Steves B, Garfikel P, Streier D, Gallop R. Relatioships betwee urses pai kowledge ad pai maagemet outcomes for their postoperative cardiac patiets. J Adv Nurs. 2001;36(4):535Y Acupucture. NIH Coses Statemet. 1997;15(5):1Y Stepheso N, Dalto JA. Usig reflexology for pai maagemet: a review. J Holist Nurs. 2003;21(2):179Y Wag HL, Keck JF. Foot ad had massage as a itervetio for postoperative pai. Pai Maag Nurs. 2004;5(2):59Y Melzack R. Pai ad stress: a ew perspective. I: Gatchel RJ, Turk DC, eds. Psychosocial Factor i Pai. New York, NY: Guilford; 1999:89Y Stepheso NL, Weirich SP, Tavakoli AS. The effects of foot reflexology o axiety ad pai i patiets with breast ad lug cacer. Ocol Nurs Forum. 2002;27(1):67Y Hulme J, Waterma H, Hillier VF. The effect of foot massage o patiets perceptio of care followig laparoscopic sterilizatio as day case patiets. J Adv Nurs. 1999;30(2):460Y Hatta J, Kig L, Griffiths P. The impact of foot massage ad guided relaxatio followig cardiac surgery: a radomized cotrolled trial. J Adv Nurs. 2000;37(2):199Y Stepheso N, Dalto JA, Carlso J. The effect of foot reflexology o pai i patiets with metastatic cacer. Appl Nurs Res. 2003;16(4): 284Y Ferrell-Torry AT, Glick OJ. The use of therapeutic massage as a ursig itervetio to modify axiety ad the perceptio of cacer pai. Cacer Nurs. 1992;16:93Y Grealish L, Lomasey A, Whitema B. Foot massage: a ursig itervetio to modify the distressig symptoms of pai ad ausea i patiets hospitalized with cacer. Cacer Nurs. 2000;23(3):237Y Tseg IC. Fr. Josef s Method of Foot Reflexology. Taipei, Taiwa: Tseg Foot Health Research Istitute; Melzack R. The short-form McGill Pai Questioaire. Pai. 1987; 30(2):191Y Seymour RA, Simpso JM, Charlto JE, Phillips ME. A evaluatio of legth ad ed-phrase of visual aalogue scales i detal pai. Pai. 1985;21(2):177Y Zigmod AS, Saith RP. The Hospital Axiety ad Depressio Scale. Acta Psychiatr Scad. 1983;67(6):361Y Steves J. Applied multivariate statistics for the social sciece. New Jersey: Lawrece Erlbaum Associates; Armitage P, Berry G, Matthews JNS. Statistical Methods i Medical Research. Oxford, UK: Blackwell Sciece; Horowitz S. Evidece-based reflexology. Alter Complemet Ther. 2004: 211Y DeDomeico G, Woods EC. Beard s Massage. 4th ed. Philadephia, PA: WB Sauders. 23. Wallace KG. The pathophysiology of pai. Crit Care Nurs Q. 1992; 15(2):1Y13. Reflexotherapy for Acute Postoperative Pai ad Axiety Cacer Nursig TM, Vol. 31, No. 2,