BBC's Defense on Their Programming on Reflexology
by Barbara and Kevin Kunz
This is the BBC's defense of their program on reflexology for Open University by Dr. Sykes. It is a really long response. Abruptly Matthew Barrett quit without allowing us to respond.
We want to start an email protest of the BBC's treatment of reflexology. Besides the questionable science we felt Dr. Sykes demonstrate extreme cultural insensitivity towards reflexology by attending a "cuddle party.'
Kevin Kunz
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Dear Mr Kunz,
I am glad to say that the series producer is now back and I am able to give you a fuller answer to your questions. Thank you for your patience. I hope the details below answer the queries you have raised in regard to the film.
As you know, reflexology is promoted for a number of medical conditions, for example, irritable bowel syndrome, asthma, menopausal symptoms, back pain, infertility, glaucoma. Early in the film we heard some powerful testimony from clients who told us they had found reflexology extremely useful for their conditions namely asthma, back pain and menopausal symptoms and later on couples struggling with infertility.
Having done that, we felt it was important to let people know the current evidence base supporting reflexology as an intervention in medical conditions. As I am sure you know, for medical treatments or therapies nowadays, scientists evaluate the clinical trials that have been done to reach an "evidence-based conclusion." This is to make sure that people do not rely on personal anecdotes or case studies - as neither provide reliable scientific evidence. It also avoids the cherry-picking of single trials that appear positive, but which can be misleading if, for example, the trial is not robust. The trials which are considered by scientists making an evidence-based assessment are usually randomised controlled trials.
In our research we looked at the findings of two evidence-based groups who had looked at reflexology: the evidence-based review by Natural Standard/Harvard and The Desktop Guide to Complementary and Alternative Medicine by Professor Edzard Ernst etc al.
Natural Standard found the evidence to be too limited to be considered for a whole host of conditions. For other conditions such as PMS, headache, or IBS it found there was unclear scientific evidence for its use or in the case of back pain fair scientific evidence against this use. There was no condition for which they considered there was good evidence for its use.
Professor Edzard Ernst gave the following opinion on the trials he cited, "It should be noted that the results of the above studies tend to be negative when placebo-effects were adequately controlled for and positive when this was not the case."
We used trials cited by these professional scientific groups as a guide to which of the published trials should be taken into account when assessing evidence; and we did our own PubMed search looking for other appropriate clinical trials which might have post-dated or escaped these sources. Of course we discovered many interesting entries in PubMed relating to reflexology, but for this section in the film we were looking specifically at medical conditions and for trials of a similar nature to those considered in the evidence-based reviews. This ruled out qualitative studies, case studies, editorial/ comment pieces or studies that were primarily concerned with wellbeing. A list of studies is attached.
We also searched the libraries of the Research Council for Comlementary Medicine, The Cochrane Collaboration, The Trip Database and the National Library of Health to alert us to any other significant papers, commentaries or evidence-based assessments. We consulted a chapter in Clinical Reflexology: A Guide for Health Professionals which reviewed research in this area and commented on its quality. We asked the Reflexology Forum and the Association of Reflexologists to make us aware of any papers that they felt we should consider in our search for evidence and we discussed the papers we had identified with them. We also had access to a report on reflexology research written in 2001 by a hospital consultant, well-disposed to reflexology, who has carried out his own small trial. This report was written in response to the House of Lords Select Committee report on CAM. We also searched the journal FACT.
Using these sources we identified around 20 relevant trials as we indicated in the commentary. The same trials were not considered by all sources, hence the approximation.
These trials looked at asthma, lower back pain, headache, IBS, constipation, PMT, menopausal symptoms, MS , Diabetes, Labour and childbirth, COPD, sino-nasal symptoms, leg oedema in pregnancy, idiopathic detrusor overactivity, and ear disorders in children. Although at this point in the programme we were not looking at more general issues of wellbeing or quality of life, we also included studies in this area which investigated the management of cancer symptoms and pain.
Overall we found that reflexology was an under-researched area something which has been commented on not just by Natural Standard as above, but by other scientists with an interest in this field .e.g. Dr Philip Tovey of the University of Leeds and Dr Andrew Vickers, an expert in trial design at the Memorial Sloan-Kettering Cancer Center. There is only occasionally more than one trial on any given condition and replication is a important factor in assessing the reliability of evidence. The Reflexology Forum also voluntarily acknowledged, in their phrase, the "fragility" of the evidence. So for the conditions reviewed there is simply not enough evidence to draw a conclusion which supports the use of reflexology.
Above all, reflexology is a therapy which is underpinned by specific theories, so a key scientific issue is whether it has any specific effects.
To explore this, trials compare reflexology to other interventions such as placebo, attention or massage. There are trials with negative results. There are also trials with positive results. However, when the positive trials were looked at more closely they were either small, solitary and/or there were methodological queries. As such, they cannot be regarded as robust or reliable evidence for the efficacy of reflexology.
We shared our research process and conclusions with the two main advisors on this film, Dr Andrew Vickers, mentioned above and Professor Stephen Holgate of the University of Southampton. Professor Holgate is one of the most eminent doctors in Britain. He advised the House of Lords Select Committee in their report on CAM in 2000. He is also a trustee of the Prince's Foundation for Integrated Health. Andrew Vickers is a leading research methodologist at the Memorial Sloan-Kettering Cancer Center. He worked previously at the Research Council for Complementary Medicine and has a particular interest in trial design in complementary medicine. We discussed the appraisal of the research in detail with Dr Vickers. Where suitable we also consulted Professor Chris Frith of University College London.
Consequently, the programme was very careful in its choice of phrasing in the section on evidence for medical benefits. We pointed out the lack of trials and said that we could find no "good evidence" that reflexology "has specific effects on an any health condition." We did not say that there was evidence reflexology does not work for any conditions and you will note we made no mention of the trials with negative findings. We merely commented there is "a real mismatch between what's claimed for reflexology and what's actually been established." We discussed these lines in detail with one of our experts and the script was also approved by the two other experts, both highly renowned scientists.
You mentioned Tina Brown's work with phantom limb pain. She has published an exploratory pilot study on 10 patients. This is a small study and not a randomized controlled trial. There are no comparison groups so what lies behind the reported benefits is not clear. This study published in May 2008 does not alter the findings above.
As well as the research above, we carried out a large amount of other research into CAMs and reflexology. And as part of this the Austrian study caught our eye, as it did yours. There are two studies, one looking at renal flow and one at intestinal flow. As only the abstracts were in English we had the entire papers translated so we could appraise them accurately. We then sought an opinion from an open-minded Professor of Physiology at a leading British university. She raised a number of concerns about the design of the study and the reporting of the data which made her question the reliability of the results. Another expert in trial design also pointed out problems with both studies for example there was information missed in the intestinal study and false inferences had been made. Both of these experts, plus another clinical neurophysiologist to whom we sent the paper, said that even if the results are taken at face value, because of the way the measurements were taken, all it shows is that massaging the central part of the foot may be causing some effect on blood flow in the body. This could well be a general effect due to massage - not limited to the arch of the foot and not specific to reflexology and not related to reflex correspondences. Also increased blood flow isn't necessarily connected in any way with improved function of the organ or a clinical benefit for the individual. We also discussed the paper with the research officer at the Association of Reflexologists. She too had sought opinions on the paper and she said one of her experts had "shot it out of the water."
For all these reasons we did not feel these studies provided the robust evidence that you clearly ascribe to them.
Of course it is quite possible foot massage may have general benefits regardless of any reflex correspondences. Or that it may produce physiological changes and we raised this in our film when we looked at massage. However, one cannot draw any evidence-based conclusions for foot massage being beneficial for medical conditions and indeed the evidence base is also limited for other forms of massage.
As the discussion above shows, our film was not only editorially sound and scientifically accurate but it was also highly responsible. From a scientific perspective we would have been open to serious criticism had we not given an evidence-based evaluation of the clinical evidence for medical conditions. We consulted a range of advisers who between them have expert knowledge on all aspects of this film. They were all entirely happy that the journey taken reflected mainstream scientific thinking.
Your last communication to the Open University suggests that you believe that there to be some contradiction between the film being a "personal and scientific journey" and it being impartial and unbiased. I do not think any of us see this contradiction since we examined the science in the utterly scrupulous and impartial manner outlined above. The personal element was to do with other aspects of the series and did not impinge upon the assessment of the evidence.
Yours sincerely
Matthew Barrett
Our Response to the Series Producer Dr. Emma Walker
July 8, 2008
Dear Ms. Walker, Mr. Salmon, Dr. Sykes,
We are writing in response to correspondence with BBC's Mr. Matthew Barrett about the series
Alternative Therapies, Reflexology
broadcast on March 24, 2008.
The BBC program represented a failure to adequately research what reflexology is and how it is
practiced. The program evolved from this laxity and resulted in a mis-characterization of reflexologists'
work, an imprecise review of research, and inexact questions asked of scientists. In addition,
the program showed not only an insensitivity to but a callous disregard for the precepts and
members of the reflexology community. Also, the omission of research evidence from the Far East
raises questions of cultural bias.
To begin, the promotion of reflexology as a alternative to medical practices or as a medical intervention
is unethical. Such action would violate the code of conduct for professional associations
not only in the United Kingdom but world wide. It is the contention of reputable reflexologists
that reflexology is a complement to and not a replacement for standard medical care.
Mr. Barrett's letter noted that "Š a range of advisorsŠ were entirely happy that the journey taken
reflected mainstream scientific thinking." Unfortunately for reflexologists, the same cannot be
said for your presentation of reflexology. The material did not reflect mainstream reflexology
thinking. As a result, the presentation of the idea, its practitioners and the evaluations by scientists
were flawed.
Reflexology was put on trial by a television crew. A trial should be scrupulously fair and honest
yet the information presented was slanted, biased and out-of-date. For example, the television
crew focused on a theory about how reflexology works, the "uric acid" theory, that has been discredited
for years among reflexology experts. Ignored were the currently accepted theories of
reflexology's impact on the nervous system and thus an individual's physical state. The on-air
anatomy presenter was asked about and noted that no direct nerve connects areas on the the foot to
the internal organs. Reflexologists agree that such a point is absurd. Again, the television crew
Reflexology Research Project, 141 San Fidel NW, Albuquerque, NM 87107
505-344-9392 € e-mail footc@maccom
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ignored current reflexology theory: reflexology's pressure techniques are interpreted by the brain
for action within the nervous system on the internal organs and other body parts.
The fact that a television crew would hazard into territory involving evidence-based research
without proper credentials is appalling to us. A perusal of research by a television crew with opinions
delivered by Dr. Sykes hardly stands up to the rigors of academic exploration. We do understand
that double-blind, randomized controlled studies are the gold standard of research. And, we
couldn't agree more with the statement that reflexology is "an under-researched area." We add the
caveat "under-researched" by Western medicine. Why didn't the television crew include a full
range of studies? In taking on the very serious task of making judgments about evidence-based
research into reflexology, the television crew displayed a cultural bias and ignored relevant
research from the Far East.
In correspondence, Mr. Barrett's contention is that advisors and experts were consulted and "the
script was also approved by the two other experts, both highly renowned scientists." Why were no
reflexology experts consulted in a similar manner? The selections of these experts, the on-air
experts and the questions posed to them were supplied by your television crew. We ask: what were
the qualifications of your television crew for selecting the experts involved and posing technical
questions to these experts?
The television crew's inclusion of a "cuddling party" in a program about reflexology is particularly
offensive. The pairing of reflexology with full body contact by complete strangers is incomprehensible
and insulting to reflexologists who are sensitive to the needs of their clientele. This
encompasses individuals who prefer reflexology services because it includes physical contact
with the feet alone, an issue especially important to those who suffer from mental illness or past
sexual abuse.
Mr. Barrett states that there is no contradiction between the personal journey of Dr. Sykes and the
scientific journey by the television crew. If the effectiveness of reflexology is to be explored, we
demand it be done, not a television crew, but by a credible scientific body with representatives
from both the West and the East as well as reflexologists.
Finally, while such programming may make "good" television, it hardly acts as a replacement for
true academic scrutiny. We ask that this program be upheld from further broadcast.
Yours truly,
Barbara K. Kunz
Kevin M. Kunz
The BBC's Response to Us
July 23, 2008
Dear Kevin,
Thank you for your letter of July 8th 2008. I will begin by addressing some of the points you have raised in your latest correspondence with us.
I would firstly like to reiterate that the aim of programme was to explore reflexology from a scientific perspective and central to that exploration were issues of evidence, mechanism and efficacy.
We did an extensive literature search, not just looking at the scientific literature but also covering websites of a large number of individual practitioners and Reflexology Associations as well as promotional and training material and a range of books - both those aimed at the public and at reflexologists. We did of course talk to people involved in the scientific field and reflexologists. There are six reflexologists in the film. But we did not want to merely rely on individual opinions which may not be representative of reflexology at large. Through this approach we were able to engage with beliefs and theories about reflexology and the benefits it is said to offer but also, very importantly, see how the majority of everyday reflexologists practice and present reflexology.
We also explored the key scientific issues which lie at the heart of complementary therapies such as reflexology and it was important that we reflected these issues within the film.
We have already given you a highly detailed account of our approach in assessing the clinical evidence base - demonstrating the thoroughness and care taken. In your latest correspondence with us, you say "the fact a television crew would hazard into territory involving evidence based research without proper credentials is appalling to us." Perhaps I can reassure you that we had researchers with science degrees working on this film: one studied Human Sciences at the University of Oxford, another has a Biology degree from Imperial College London and another researcher has a degree in Biological Sciences again from The University of Oxford and a PhD in Neuroscience. I am a qualified Medical Doctor and have an additional science degree in Pathology both degrees from The University of Edinburgh. So we are all scientifically literate, able to gather together the relevant material and ask appropriate questions.
Furthermore, as we laid out in our previous letter, the studies we considered and the evidence based conclusion in the programme, drew on and reflected the opinions and observations of other scientists who have commented on or surveyed this field. This does not represent cultural bias. We shared our research process and conclusions with highly eminent expert advisers.
In the film we never say or suggest that reflexologists encourage people to have reflexology in place of their medical treatment.
Practitioners' sites and other promotional literature commonly recommend reflexology as being useful, or of benefit, or effective for conditions such as irritable bowel syndrome, digestive disorders, menopausal symptoms, PMS, back pain, chronic fatigue, migraine, and asthma. Some sites go beyond this to include ailments such glaucoma, hypertension, liver disease and more. The Association of Reflexologists website states: "Reflexology has been shown to be effective for back pain, migraine, infertility, arthritis, sleep disorders, hormonal imbalances, sports injuries, digestive disorders and stress related conditions".
Therefore reflexology is being promoted to help with specific ailments and people use it on this basis. So it was not just reasonable to have looked at the clinical evidence it was essential.
You say that uric acid theory has been discredited for years. However this idea is repeatedly found on websites of practicing reflexologists and we reflect this. As Professor Sykes says "Some reflexologists claim that part of what they're doing is breaking down uric acid crystals in the base of the feet"
Reflexology is based on the principle that, "In the feet, there are reflex areas corresponding to all the parts of the body and these areas are arranged in such a way as to form a map of the body in the feet with the right foot corresponding to the right side of the body and the left foot corresponding to the left side of the body." ( The British Reflexology Association). Or as the International Federation of Reflexologists states: "Reflexology today is a precisely defined form of treatment based on the principle that the anatomy of the body is reflected in miniature on reflex zones on the feet and also on the hands (though a little less defined). By using specific techniques of holds and pressures on these regions, healing is both initiated and accelerated in the corresponding area of the body" .This idea and the foot map, which details which parts of the feet correspond to which parts of the body, lie at the very heart of reflexology practice. Because this foot map can be said to define reflexology it was vital we addressed it.
Reflexologists put forward different ideas about how this mapping of the body onto the foot might work. A common explanation cited on websites and in books is through zones, or energy channels, and that working a specific area or reflex on the foot clears energy blockages or congestions in the corresponding part of the body. Some practitioners say that it involves the nervous system in some way. For example when Mr. Dwight Byers met Professor Sykes he said "Somehow the nervous system to us seems to be involved."
However the point here is that Dr Alice Roberts is attempting to look at how the foot map might work according to conventional understanding of the body. How might specific parts of the feet be linked with specific parts of the body? As we say in the commentary the most likely way from a conventional viewpoint is through the nervous system. Dr Roberts therefore explained that she cannot see how this would work as there are no direct nerve pathways.
Professor Sykes then asks Dr Roberts if it could work via the brain and she replies that it could happen in a generalised way. In other words not in a way that supports the idea of the body being mapped onto the foot, but a general response to foot massage per se and we pick this idea up later in the film in the sections on massage and touch.
During our research we discussed the foot map and the zones with a number of neurophysiologists who were of the same opinion.
Of course, as we say, foot massage may well produce physiological changes and we raise this very idea later in the film in the section where we look at massage. We also show in this section that even with massage, the precise physiological changes and their possible influence on health are only just beginning to be investigated systematically.
In the last part of the film Kathy turned her attention away from reflexology to massage and touch. In the section on touch we featured a cuddle party. We made no link between the cuddle party and the practice of reflexologists. It was merely an engaging way to show how much people value touch and respond to it and I am surprised at your reaction. Finally we showed an extremely interesting study in Virginia using fMRI to explore the effects of friendly touch and we postulate that maybe this could be happening with reflexology.
Having addressed the points you have raised I feel it would now be useful to look at the film as a whole and not just the sections above in isolation.
In the film we show people who really value reflexology and report benefits for conditions such as asthma, back pain, menopausal symptoms and infertility. We point out this is anecdote not evidence a key scientific principle. We go on to say there is a lack of clinical evidence and that there is no known neurophysiological basis for the idea that the body is mapped onto the sole of the foot. However we also show that people don't really care about this if they feel it works for them.
We also examine the role of reflexology and massage in helping people with anxiety or emotional burdens such as cancer, though relaxation. This is an increasingly popular use of reflexology. In the film we featured a patient being treated for cancer who felt she had really benefited from reflexology.
And we also consider three ways that reflexology may have an effect, which are perfectly in line with conventional scientific thinking; possibly through massage and touch, which we have already discussed, and also through placebo/context effects.
Placebo, or context effects, are a hot scientific topic in the discussion of CAMs. In fact in May this year it was the subject of a research paper and the lead editorial in the British Medical Journal. We decided to look at the latest thinking on this subject by a leading figure in the field who showed us that this effect is not something to be dismissed but an incredibly powerful intervention in itself and that reflexology was likely to be tapping into this.
I hope this and the previous letter have covered the points you have raised. If you are still unhappy you should know that you can complain to the BBC's Editorial Complaints Unit at 5170, White City, Media Village, 201 Wood Lane, London W12 7TS.
With best wishes,
Yours sincerely,
Emma
Dr Emma Walker
Series Producer
BBC Vision Studios
Tel: +44-20-800 82567
020 800 82567
Int: x 82567
