الفهرس 
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Abstract
Hemodialysis is used to remove fluid and uremic waste products from the body when the kidneys cannot do so. Fatigue is a common side effect in patients undergoing hemodialysis. It is thought to be caused by a combination of the loss of normal kidney function, the effects that dialysis can have on the body, the dietary restrictions associated with dialysis, and the overall stress and anxiety that many people with kidney failure experience. On the other hand, leg cramps are common problem in patients undergoing hemodialysis. It often results in the early termination of a hemodialysis session and is therefore a significant cause of under dialysis. The exact etiology of cramps in dialysis patients is unknown and effective anti-cramp medicine is not available.
The use of reflexology massage by nurses is easy and practical; it can be performed at any location, is non-invasive, and does not interfere with patients’ privacy. Reflexology massage has been widely used in fields which include midwifery, orthopedics, neuroscience and palliative care.
This study aimed to evaluate the effectiveness of reflexology foot massage on fatigue levels and leg cramps for hemodialysis patients
Materials and method:
Materials:
Research design: A quasi experimental research design was used in the present study.
The study was conducted at the hemodialysis units of El - Moassat University Hospital and Dr. Montasser Zeid Nephrology Center.
The subjects of this study comprised 66 adult patients undergoing hemodialysis, divided equally into study and control groups, 33 patients each.
Five tools were used in this study: Tool I: Hemodialysis Patients Assessment Tool: It was constructed by the researcher after review of relevant literature and it was consisted of two parts: Part (I): Patient’s Sociodemographic characteristics and Part (II): Clinical Data. Tool II: Visual Analog Fatigue Scale (VAFS) to measure fatigue intensity. Tool III: Multidimensional Fatigue Scale: It was constructed by the researcher, it assess fatigue related to 4 dimensions physical, psychological, mental and social. It is assessed on a 4 point rating scale ranging from (0) = Never experience fatigue, (1) = Rarely experience fatigue, (2) = Often experience fatigue and (3) = Almost always experience fatigue (severe and continuous). Tool IV: Leg Cramps Intensity Scale: for assessing leg cramps intensity. Tool V: Leg Cramps Assessment: It was developed by the researcher and it was consisted of two parts: Part (I): assess leg cramps: Site, onset, alleviating factors, duration and frequency. Part (II): it was consisted of items related to leg cramps effect on: Sleep pattern, physical activities, emotional well- being and social activities.
Method of the study
A written approval to carry out the study was obtained from the general director of Al - Moassat Hospital and Dr. Montasser Zeid Nephrology Center and from the head of the department of medical nephrology unit of Al- Moassat Hospital.
Tool I, Tool III and Tool V were developed by the researcher and were translated into Arabic. Content validity for both English and Arabic versions were tested by 5 experts in the field of medical surgical nursing and 4 experts in nephrology medicine.
Reliability of the tools was done using Cronbach’s Alpha
The researcher received a training course covered over 30 credit hours on using reflexology foot massage techniques, in the Open Academy of Complementary Center present in Cairo. The researcher got a certificate which has been certified from Cairo University and the Ministry of Foreign Affairs.
A pilot study was carried out on 7 patients from the study settings to check and ensure the clarity and applicability of the tools and the necessary modifications were carried out.
Data collection was carried out in two phases: data related to the control group and data related to the study group.
The researcher observed every patient in the control group during the whole period of the hemodialysis session and when cramps occur during the hemodialysis, leg cramp assessment was taken as the following:
a. When cramps start using Tool IV: leg cramps intensity Scale (every subject was trained on how to use visual analogue scale before starting the study).
b. Immediately after 5 minutes using Tool IV: (leg cramps intensity Scale) and part (I) of Tool V (Leg cramps assessment sheet).
Fatigue severity was assessed to every patient in the control group immediately after the hemodialysis session & after 40 minutes, using Tool II: Visual Analog Fatigue Scale.
Fatigue and leg cramps of the control group were assessed using Tool III (Multidimensional Fatigue Scale) and Tool V (Leg cramps Assessment Tool) four times. First assessment done by asking the patient about fatigue and leg cramps during the week before the first contact of the researcher with the subject, second assessment after one week, third assessment after two weeks, fourth assessment after three weeks.
The researcher observed every study subject during the whole period of the hemodialysis session which lasts approximately 4 hours and when cramps occur during the hemodialysis, sub session for 5 minutes was done by applying pressure to solar plexus point, leg point and sciatic nerve point in the foot of the affected leg. Leg cramps assessment was taken as the following:
a. Immediately before sub session using Tool IV: leg cramps intensity Scale (every study subject was trained on how to use visual analogue scale before starting the study).
b. Immediately after sub session using Tool IV: (leg cramps intensity Scale) and part (I) of Tool V (Leg cramps assessment sheet).
Every patient in the study group was received complete reflexology foot massage session for 40 min (20 min for each foot) to all reflex points in the foot guided by reflexology foot massage map. It was done immediately after the hemodialysis session.
Fatigue severity was assessed immediately before and immediately after the complete reflexology foot massage session, using Tool II: Visual Analog Fatigue Scale.
Fatigue and leg cramps were assessed, using Tool III (Multidimensional Fatigue Scale) and Tool V (Leg cramps Assessment Tool) four times. First assessment before applying any reflexology foot massage session asking the patient about fatigue and leg cramps during the week before the first contact of the researcher with the subject, second assessment after applying three sessions (after one week), third assessment after applying six sessions (after two weeks), fourth assessment after applying nine sessions (after three weeks).
Results of the study revealed that:
The results of the present study revealed that there were no statistical significant differences in sociodemographic and clinical data between the study and control groups which included age, sex, marital status, the level of education, duration of hemodialysis and/or inter- dialytic weight gain.
There were no statistical significant differences between both groups in relation to fatigue intensity among patients on hemodialysis, before first, second, third and fourth application of reflexology foot massage sessions. While, there were statistical significant improvement (p=0.007* and 0.006*) respectively before the fifth and sixth sessions in the study over control group, moreover before the seventh, eighth and ninth sessions and after all ninth sessions significance was (p = <0.0001*) in the study group over control.
There was no statistical significant difference between both study and control groups mean (78.3, 79.9) respectively regarding total fatigue dimensions scores before receiving interventions while there was statistical significant lowering of total fatigue dimensions scores in the study group than in the control group after receiving 3 massage sessions, 6 massage sessions and 9 massage sessions mean (52.1, 80.5), (31.2, 81.5) and (26.7, 82.8) respectively.
The findings of the study revealed that there was no statistical significant difference between the study and control groups in relation to leg cramps intensity, duration, alleviating factors, and frequency before interventions. While, patients on haemodialysis experienced significantly decreased leg cramps intensity (p = 0.0001*, 0.0001*, 0.0001*, 0.005*, 0.0001*, 0.005*, 0.0001*, 0.009*, <0.0001*) respectively throughout the nine massage sessions among the studied patients over the control. Regarding duration of leg cramps during all nine hemodialysis sessions, there was statistical significant difference (p=<0.0001*, <0.0001*, <0.0001*, 0.0001*, 0.003*, 0.006*, 0.007*, 0.017* and 0.042*) respectively in the study group over the control.
In relation to leg cramps effect on sleep the difference was not statistically significant before applying massage for study and control groups. Meanwhile, there was statistical significant improvement in sleeping pattern in the study than control group. Regarding, total scores of leg cramps effect on physical activities, emotional well-being and social activities the difference was not statistically significant before applying massage for study and control groups mean (29.7, 32.1) respectively. while there was statistical significant improvement in leg cramps effect on physical activities, emotional well-being and social activities total scores in the study group than in the control group after receiving 3 massage sessions, 6 massage sessions and 9 massage sessions mean (5.9, 47.0), (0.0, 32.5) and (0.0, 33.4) respectively.
It was concluded that
Patients on hemodialysis underwent a course of 40 minutes reflexology massage after the hemodialysis session on all reflex points on both feet, 3 times per week, for 3 consecutive weeks with a total of 9 massage sessions; resulted in significant decrease of fatigue intensity levels, leg cramps frequency and duration, improvement of physical activities, mental and psychological wellbeing, sleeping pattern and social functions.
Application of reflexology foot massage sub session for 5 minutes by applying pressure to solar plexus point, leg point and sciatic nerve point in the foot of patients suffering from leg cramps during the hemodialysis session resulted in significant decrease of leg cramps intensity and duration.
Recommendations:
The findings of this study lead to the following recommendations:
Reflexology foot massage should be used as evidence base for nursing practice with patients on hemodialysis through the following:
• Incorporate the technique in clinical nursing curricula, so that students will be trained to use it as an integral part of the care of patients on hemodialysis.
• Teach the technique to faculty teaching staff and their assistants in order to be proficient in demonstrating it to their students.
• Approach the administrative personnel of hemodialysis unit, in order to raise their awareness about the benefits of reflexology to patients on hemodialysis, so that they may cooperate with the nursing faculty staff in educating the reflexology technique to the clinical nurses and encouraging its use as an integral part of patient’s care.
Recommendations for further research:
• Compare reflexology foot massage with other complementary medicine methods in relieving fatigue and leg cramps of patients on hemodialysis.
• Research on cost-effectiveness, gender and aging differences associated with reflexology.
• Evaluate the effects of foot reflexology on outcome variables other than fatigue and leg cramps.