1. Introduction
ain is a common phenomenon after all surgeries. Approximately 70% of patients complain of severe pain on the first day after surgery. Pain delays wound healing and increases the chances of developing thromboembolic disorders. High levels of pain after surgery increase drug use, decrease lung capacity, cause pneumonia or tachycardia, increase blood pressure, delay recovery, and prolong hospital stay. Although medication is the most common pain management intervention, the prevalence of postoperative pain is still reported in up to 80% of cases. Drug side effects and other existing problems such as lack of access or inadequacy of painkillers to relieve pain have led to the attention of nursing systems to non-pharmacological pain relief techniques. One of the non-pharmacological approaches is complementary medicine. Foot Reflexology is one of the most common methods of complementary therapies. This method is done by applying pressure on the sole of the foot with the help of fingers, especially the thumb, to change the body’s energy flow. The advantages of this method include cheapness and cost-effectiveness, patient satisfaction, ease of use and independence of technology. Considering the frequency of tibial plateau fractures and severe pain in after plating surgery, the present study was performed to determine the effect of foot reflexology massage on postoperative pain in patients undergoing tibia plating surgery.
2. Materials and Methods
In this randomized clinical trial, 96 patients referred to Imam Ali Hospital in Bojnourd, Iran who were candidates for tibia plating surgery were studied in two groups of intervention (n=48) and control (n=48). Inclusion criteria were: age 18-75 years, any tibial plateau fracture that requires surgery according to the surgeon, health of the soles and toes and no fractures in other parts, and no vascular disease, inflammation, diabetes, sensory-motor impairments, drug and alcohol addiction, chronic pain such as migraine, and history of receiving massage. Exclusion criteria were: patients’ dissatisfaction at each stage of follow-up, instability of hemodynamic status after surgery, and failure to achieve suitable environmental conditions for the intervention. After obtaining the informed consent and one hour before the surgery, the reflexology massage of the sole of the foot was performed in the intervention group for 10 minutes; for the control group, the foot sole was touched for one minute without any pressure. Patients’ pain intensity was measured using the standard Visual Analog Scale (scored on a 10-point scale) before and immediately after the intervention, and at 2, 4, 6, 12 and 24 hours after surgery. To analyze the data, chi-square tests (for qualitative variables), t-test and repeated measure ANOVA (for quantitative variables) as well as Mann-Whitney U and Friedman tests were used. The P value less than 0.05 was considered as the statistically significance level.
3. Results
Of 96 participants, 34 (35.4%) were female and 62 (64.6%) were male. The patients in the two study groups were similar in terms of demographic characteristics. The difference between the mean pain scores in the intervention and control groups was statistically significant immediately after and 2, 4, 6, 12 and 24 hours after surgery, where patients in the intervention group had lower mean pain than the control group (Table 1). 



The pain intensity in the control group was also significantly reduced, but the reduction was relatively greater in the intervention group. Figure 1 compares the declining trend between the two groups. No any significant complication was observed in the groups. 
 
4. Conclusion
Foot Reflexology massage reduces postoperative pain in patients undergoing tibia plating surgery. Due to the lack of reporting of any specific complication, this method can be used to reduce pain in orthopedic surgery patients.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Mazandaran University of Medical Sciences (Code: IR.MAZUMS.REC.1399.110), and is a registered clinical trial (Code: IRCT20200502047265N1).
Funding
The present paper was extracted from the MSc. thesis of the first, Department of Operating Rome, School of Allied Medical Sciences, Medical Student Research Committee, Mazandaran University of Medical Sciences, Sari. 
Authors' contributions
Conceptualization: Ebrahim Nasiri and Mohammad Reza Safdari; Methodology: Fatemeh Imani and Mohammad Reza Safdari; Data analysis: Ebrahim Nasiri and Fatemeh Imani; Editing & review: All authors.
Conflicts of interest
The authors declared no conflict of interest.
Acknowledgements
The authors would like to thank the Deputy for Research and Technology of Mazandaran University of Medical Sciences and North Khorasan University of Medical Sciences, patients, operating room staff and orthopedic department of Imam Ali Hospital for their valuable cooperation.


References

1. Khoshtarash M, Ghanbari A, Yegane MR, Kazemnejhad E, Rezasoltani P. [Effects of foot reflexology on pain and physiological parameters after cesarean section (Persian)]. Koomesh. 2012; 14(1):109-16. http://koomeshjournal.semums.ac.ir/article-1-1299-en.html
2. Eghbali M, Safari R, Nazari F, Abdoli S. The effects of reflexology on chronic low back pain intensity in nurses employed in hospitals affiliated with Isfahan University of Medical Sciences. Iranian Journal of Nursing and Midwifery Research. 2012; 17(3):239-43. http://ijnmr.mui.ac.ir/index.php/ijnmr/article/view/485
3. Mansour Ghanaee M, Mirblook F, Boini S, Erfani Shayyar R, Shakiba M, Naghdi Pour M, et al. [The analgesic effects of gabapentin after total abdominal hysterectomy (Persian)]. Iranian Journal of Obstetrics, Gynecology and Infertility. 2012; 15(1):17-25. [DOI: 10.22038/IJOGI.2012.5747]
4. Mohammad Hosseini S, Elahi N, Meshksaran S, Raskh A, Mohebi Nobandeghani Z. [Effect of electrical nerve stimulation Percutaneously in pain control after femour fracture surgery (Persian)]. Armaghan Danesh. 2002; 7(27):9-16. https://www.sid.ir/fa/journal/ViewPaper.aspx?id=16610
5. Fayazi S, Shahriati A, Momeni M. [The efficacy of Benson’s relaxation technique on postoperative pain in coronary artery bypass graft (Persian)]. journal of JundiShapur Educational Development. 2010; 8(4):479-89. https://www.sid.ir/fa/journal/ViewPaper.aspx?id=100825
6. Sammour RN, Ohel G, Cohen M, Conen R. Oral naproxen versus oral tramadol for analgesia after cesarian delaivery. International Journal of Gynecology & Obstetrics. 2011; 113(2):144-7. [DOI:10.1016/j.ijgo.2010.11.024] [PMID]
7. Lowenstein L, Zimer EZ, Deutsch M, Paz Y, Yaniv D, Jakobi P. Preoperative analgesia with local lidocaine infiltration for abdominal hysterectomy pain management. European Journal of Obstetrics, Gynecology and Reproductive Biology. 2008; 136(2):239-42. [DOI:10.1016/j.ejogrb.2006.11.008] [PMID]
8. Vadivelu N, Mitra S, Narayan D. Recent advances in postoperative pain management. The Yale Journal of Biology and Medicine. 2010; 83(1):11-25. [PMCID] [PMID]
9. Dekeyser FG, Cohen BB, Wagner N. Knowledge levels and attitudes of staff nurses in Israel towards complementary and alternative medicine. Journal of Advanced Nursing. 2001; 36(1):41-8. [DOI:10.1046/j.1365-2648.2001.01941.x] [PMID]
10. Khaledifar A, Nasiri M, Khaledifar B, Khaledifar A, Mokhtari A. The effect of reflexotherapy and massage therapy on vital signs and stress before coronary angiography: An open-label clinical trial. ARYA Atherosclerosis. 2017; 13(2):50-5. http://arya.mui.ac.ir/index.php/arya/article/view/1232/1506
11. Rezaei R, Saatsaz S, Alipour A, Beheshti Z. [Massage-therapy and post cesarean pain control (Persian)]. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2017; 20(4):34-43. [DOI: 10.22038/IJOGI.2017.8979]
12. Memarian R, Vanaki Z, Kelateh Jari M. [The effect of Bensons relaxation methods on anxiety of patients before abdominal surgery in men ward (Persian)]. Daneshvar Medicine. 2000; 8(30):65-70. https://www.sid.ir/en/journal/ViewPaper.aspx?ID=32971
13. Kaur J, Kaur S, Bhardwaj N. Effect of ‘foot massage and reflexology’ on physiological parameters of critically ill patients. Nursing and Midwifery Research Journal. 2012; 8(3):223-33. [DOI:10.33698/NRF0140]
14. Blunt B. Foot reflexology. Holistic Nursing Practice. 2006; 20(5):257-9. [DOI:10.1097/00004650-200609000-00009] [PMID]
15. Silva NCM, Chaves ÉCL, Carvalho EC, Carvalho LC, Iunes DH. Effect of foot reflexology on capillary blood glucose, tissue temperature, and plantar pressure of individuals with diabetes mellitus (type 2): A pilot study. Journal of Chiropractic Medicine. 2018; 17(3):182-9. [DOI:10.1016/j.jcm.2018.03.003] [PMID] [PMCID]
16. Nasiri K, Eyvanbagha R, Nazari N, Savadpoor M-T, Soleymanifard P, Khalili Z. [Physiological and therapeutic effects of reflexology in Iran: a systematic review (Persian)]. Depiction of Health. 2016; 7(1):49-61. https://doh.tbzmed.ac.ir/Article/doh-148
17. Ernest E. Is reflexology an effective intervention? A systematic review of randomised controlled trials. Medical Journal of Australia. 2009; 191(5):263-6. [DOI:10.5694/j.1326-5377.2009.tb02780.x] [PMID]
18. Mathúna DPO. Evidence-based practice and reviews of therapeutic touch. Journal of Nursing Scholarship. 2000; 32(3):279-85. [DOI:10.1111/j.1547-5069.2000.00279.x] [PMID]
19. Kavei P, Ebadi A, Saeed Y, Moradian ST, Sedigh -Rahimabadi M. [Effect of foo reflexology on anxiety and agitation in patients under mechanical ventilation after open heart surgery: A randomized clinical trial study (Persian)]. Journal of Clinical Nursing and Midwifery. 2015; 4(1):16-26. http://jcnm.skums.ac.ir/article-1-212-en.html
20. Sahbaee F, Abedini SH, Ghandehari H, Zare M. [The effect of foot Reflexology Massage on pain of scoliosis patients undergoing spinal surgery (Persian)]. Journal of Anesthesiology and Pain. 2015; 5(4):63-71. http://jap.iums.ac.ir/article-1-5173-en.html
21. Maryami Z, Modarresi M, Taavoni S, Rahimiforoushani A. [The effect of foot massage on pain of patients after hysterectomy (Persian)]. Journal of Knowledge & Health. 2018; 12(4):61-8. [DOI:10.22100/jkh.v12i4.1698]
22. Shahriari M, Khalili A, Shamsizadeh M, Mardani D, Paymard A, Vardanjani MM.[Efects of foot reflexology on pain in patiants after lower limb amputation (Persian)]. Journal of Mazandaran University of Medical Sciences. 2016; 26(139):18-26. http://jmums.mazums.ac.ir/article-1-8151-en.html
23. Ramezanibadra F, Amini K, Hossaingholipora K, Faghihzadehc S. The impacts of foot reflexology on anxiety among male candidates for coronary angiography: A three-group single-blind randomized clinical trial. Complementary Therapies in Clinical Practice. 2018; 32:200-4. [DOI:10.1016/j.ctcp.2018.07.005] [PMID]
24. Lalehgani H, Rafiei Z, Yarmohammadi P. [The effect of foot reflexology massage on pain of patients undergoing lumbar disc surgery in shahrekord hospitals (Persian)]. Journal of Clinical Nursing and Midwifery. 2018; 7(1):19-27. http://jcnm.skums.ac.ir/article-1-824-en.html
25. Bertrand A, Mauger-Vauglin  C-E, Martin S, Goy F, Delafosse C, Marec-Berard P. Evaluation of efficacy and feasibility of foot reflexology in children experiencing chronic or persistent pain. Bulletin du Cancer. 2019; 106(12):1073-9. [DOI:10.1016/j.bulcan.2019.05.008] [PMID]
26. Albert NM, Gillinov AM, Lytle BW, Feng J, Cwynar R, Blackstone EH. Randomized trial of massage therapy after heart surgery. Heart & Lung. 2009; 38(6):480-90. [DOI:10.1016/j.hrtlng.2009.03.001] [PMID]
27. Sadeghi Shermeh M, Bozorgzad P, Gafourian AR, Ebadi A, Razmjoei N, Afzali M, et al. [Effect of foot reflexology on sternotomy pain after coronary artery bypass graft surgery (Persian)]. Journal of Intensive Care Nursing. 2009; 2(2):51-4. http://jccnursing.com/article-1-117-en.html
28. Hattan J, King L, Griffiths P. The impact of foot massage and guided relaxation following cardiac surgery: A randomized controlled trial . Journal of Advanced Nursing. 2002; 37(2):199-207. [DOI:10.1046/j.1365-2648.2002.02083.x] [PMID]
29. Stephenson N, Dalton JA, Carlson J. The effect of foot reflexology on pain in patients with metastatic cancer. Applied Nursing Research. 2003; 16(4):284-6. [DOI:10.1016/j.apnr.2003.08.003] [PMID]
30. Keller G. The effects of massage therapy after decompression and fusion surgery of the lumbar spine: A case study. International Journal of Therapeutic Massage and Bodywork. 2012; 5(4):3-8. [DOI:10.3822/ijtmb.v5i4.189] [PMID] [PMCID]