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
***************************************************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