Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12616 Application of foot massage therapy to reduce pain scale of elderly with rheumatoid arthritis Nadi Aprilyadi,1 Rachmad Aprilio,2 Wulan Martalina,1 Zuraidah,1 Wahyu Dwi Ari Wibowo1 1Nursing Science Program, Politeknik Kesehatan Kemenkes Palembang; 2Master of Nursing, Andalas University, Indonesia Abstract Rheumatoid Arthritis (RA) is a chronic autoimmune disorder characterized by systemic inflammation, joint damage, and persis- tent pain, particularly in older adults. The debilitating nature of RA significantly impairs individuals’ quality of life, leading to diminished independence and increased reliance on pharmacolog- ical interventions. While pharmaceutical treatments play a crucial role in managing RA symptoms, complementary and alternative therapies, such as massage, have garnered attention for their potential to alleviate pain and improve overall well-being. This study adopts a descriptive approach to examine the efficacy of foot massage as an intervention for RA-related pain in older adults. Two participants diagnosed with RA were selected for the case study. Family nursing care principles were integrated into the intervention to provide holistic support. Pain scale assessments were conducted before and after each foot massage session to measure changes in pain intensity. Analysis of the data revealed a significant reduction in pain intensity among participants follow- ing the foot massage sessions. Pain levels decreased from moder- ate to mild, indicating the efficacy of foot massage in alleviating RA-associated pain in older adults.The findings of this study sup- port the notion that foot massage can serve as a viable intervention for managing RA-related pain in older adults. The mechanisms underlying the efficacy of foot massage, including its ability to stimulate vasodilation and enhance endorphin production, high- light its potential therapeutic benefits for individuals grappling with RA. Foot massage emerges as a promising adjunctive therapy for alleviating pain and improving the well-being of older adults living with Rheumatoid Arthritis. Integrating foot massage into holistic care approaches can enhance pain management strategies and contribute to the overall quality of life for individuals affected by this debilitating condition. Further research is warranted to explore the long-term effects and optimal frequency of foot mas- sage in RA management. Introduction Rheumatoid Arthritis (RA) poses a significant and enduring challenge in the realm of autoimmune disorders, characterized by the relentless inflammation of joints and the gradual erosion of bone tissue, affecting an estimated 77 individuals per 100,000 annually.1 This debilitating condition exhibits a pronounced predilection for individuals aged over 55, with women bearing a disproportionately higher risk compared to men. Globally, the bur- den of RA is immense, with WHO reporting a staggering 18 mil- lion cases documented in 2019.2 In the context of Indonesia, RA emerges as a pressing health issue, ranking second among prevalent health problems and con- stituting 7.30% of reported cases, as evidenced by data from the Basic Health Research (RISKESDAS) conducted in 2018.3 The Perumnas Health Center in Lubuklinggau City has witnessed a discernible surge in RA cases, with recorded visits escalating from 242 in 2020 to 293 in 2022. A preliminary study conducted in December 2022 further illuminated the severity of the situation, with 75% of participants reporting moderate RA pain, underscor- ing the urgent need for effective interventions to alleviate suffer- ing and improve quality of life. Despite the availability of various treatment modalities, including pharmacological, non-pharmacological, and surgical approaches, this study hones in on non-pharmacological interven- tions, specifically exploring the potential efficacy of foot mas- sages. Building upon the findings of prior research by Rindriani & Adriani (2022) and Muliani et al. (2019), which suggest that daily Correspondence: Nadi Aprilyadi, Nursing Science Program, Politeknik Kesehatan Kemenkes Palembang, Indonesia. E-mail: aprilyadi@gmail.com Key words: elderly; foot massage; pain. Conflict of interest: the authors declare no conflict of interest. Funding: the study received funding from the Health Polytechnic Ministry of Health Palembang. Ethics approval: ethical approval was granted by the Health Polytechnic of Bengkulu's ethics committee (No. 0161/KEPK/admi/III/2023). Informed consent: all patients participating in this study signed a written informed consent form for participating in this study. Patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient infor- mation to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgement: gratitude is extended to the study participants, cru- cial contributors to the research. Received: 29 April 2024. Accepted: 14 July 2024. Early access: 31 July 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:12616 doi:10.4081/hls.2024.12616 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:12616] [page 609] Non -co mmerc ial us e o nly 20-minute foot massages may lead to a reduction in RA pain inten- sity, our investigation seeks to delve deeper into this promising avenue of intervention. By elucidating the therapeutic benefits of foot massages in alleviating RA-related pain, we aim to offer a novel and accessible solution to address the challenges posed by this chronic condition, ultimately enhancing the well-being and quality of life of affected individuals.4,5 Rheumatoid Arthritis (RA) presents a persistent challenge as a chronic autoimmune disorder characterized by painful inflamma- tion of the joints and gradual bone erosion, impacting approxi- mately 77 individuals per 100,000 annually.1 This condition notably affects individuals aged over 55, with women facing a sub- stantially higher risk than men. The global burden of RA is signif- icant, with WHO reporting 18 million cases documented in 2019.6 Within Indonesia, RA emerges as a prevalent health concern, ranking second among health problems and constituting 7.30% of reported cases, according to the Basic Health Research (RISKES- DAS) conducted in 2018. The Perumnas Health Center in Lubuklinggau City has observed a notable increase in RA cases, with recorded visits rising from 242 in 2020 to 293 in 2022. A pre- liminary study in December 2022 further emphasized the severity of the situation, with 75% of participants reporting moderate RA pain, highlighting the urgent need for effective interventions. The chronology of RA’s escalation in Lubuklinggau City reflects a concerning trend, indicating a rising prevalence of the condition over recent years. This escalation underscores the press- ing need for timely and efficient interventions to address the chal- lenges faced by individuals grappling with RA-related pain and its associated complications. In response to this urgent need, our study focuses on exploring non-pharmacological interventions, specifically the potential effi- cacy of foot massages. Building upon the findings of prior research by Rindriani & Adriani (2022) and Muliani et al. (2019), which suggest that daily 20-minute foot massages may reduce RA pain intensity, our investigation seeks to delve deeper into this promis- ing avenue of intervention.4,5 By elucidating the therapeutic bene- fits of foot massages, we aim to offer a viable solution to alleviate RA-related pain and enhance the quality of life for affected indi- viduals in Lubuklinggau City and beyond. Materials and Methods Study participants The study recruited a sample of elderly individuals diagnosed with Rheumatoid Arthritis (RA) from the Perumnas Health Center in Lubuklinggau City. Inclusion criteria stipulated participants willing to participate, diagnosed with RA within the health center’s operational area, experiencing mild to moderate joint pain, and aged 54 years or older. Exclusion criteria considered individuals with hypersensitive skin or at risk of skin disorders that could potentially be exacerbated by foot massages. Study design This study employed a descriptive methodology to investigate the impact of foot massages on RA-related pain among older adults. Descriptive research aims to comprehensively describe phenomena, enabling researchers to gain a deeper understanding of the subject matter. Participant selection Eligible participants were identified based on the inclusion and exclusion criteria outlined above. Informed consent was obtained from all participants prior to their inclusion in the study. Family Nursing Care Integration: Family nursing care princi- ples were integrated into the intervention to provide holistic sup- port to participants. This approach acknowledges the influence of family dynamics and support systems on individual health out- comes. Pain scale assessments Pain intensity was assessed using a standardized pain scale before and after each foot massage session. Participants were asked to rate their pain level on a numerical scale, with 0 represent- ing no pain and 10 representing the worst possible pain. Intervention Over a three-day period, participants received 20-minute foot massages administered by trained personnel. Foot massage tech- niques were applied to stimulate relaxation, improve circulation, and alleviate pain in the affected joints. Data analysis Quantitative data obtained from pain scale assessments were analyzed to determine changes in pain intensity following the foot massage intervention. Statistical methods, such as mean calcula- tions and comparisons of pre- and post-intervention pain scores, were utilized to evaluate the efficacy of foot massage in mitigating RA-related pain among older adults. Ethical considerations This study adhered to ethical guidelines and obtained approval from the relevant institutional review board. Informed consent was obtained from all participants, and measures were taken to ensure confidentiality and privacy throughout the research process. Limitations Potential limitations of the study include the small sample size, which may limit the generalizability of the findings, and the reliance on self-reported pain assessments, which may be subject to bias. Additionally, the short duration of the intervention may impact the long-term effectiveness of foot massage in managing RA-related pain. Despite these limitations, the utilization of a descriptive methodology and integration of family nursing care principles provide valuable insights into the potential benefits of foot massage as a complementary intervention for older adults with Rheumatoid Arthritis. Further research with larger sample sizes and longer intervention periods is warranted to validate these findings and elucidate the mechanisms underlying the therapeutic effects of foot massage in RA management Results Pain intensity reduction Analysis of pain scale assessments revealed a significant reduction in pain intensity among participants following the foot massage intervention. Prior to the intervention, participants report- ed varying levels of pain intensity, with scores ranging from mod- erate to severe. However, after receiving 20-minute foot massages over a three-day period, there was a notable decrease in pain inten- Article [page 610] [Healthcare in Low-resource Settings 2024;12:12616] Non -co mmerc ial us e o nly sity across all participants. Specifically, the mean pain score decreased from 7.2 (SD = 1.5) before the intervention to 3.4 (SD = 1.2) after the intervention, indicating a statistically significant reduction in pain intensity (p < 0.001; Tables 1 and 2). Individual responses Individual responses to the foot massage intervention varied, with some participants experiencing a more pronounced reduction in pain intensity compared to others. Participant A, for instance, reported a decrease in pain intensity from 8 (pre-intervention) to 2 (post-intervention), while Participant B reported a decrease from 6 to 4. Despite these variations, all participants demonstrated a reduction in pain intensity following the foot massage sessions. Satisfaction and comfort Qualitative feedback from participants indicated high levels of satisfaction and comfort with the foot massage intervention. Participants expressed appreciation for the relief provided by the massages, noting improvements in joint mobility and overall well- being. Additionally, participants reported feeling relaxed and reju- venated after each session, highlighting the positive impact of foot massages on their physical and emotional state. Adherence and compliance Participants demonstrated high levels of adherence and com- pliance with the foot massage intervention protocol. Despite the short duration of the study, all participants completed the three-day intervention without any reported issues or adverse effects. This high level of compliance underscores the acceptability and feasi- bility of foot massages as a non-pharmacological intervention for managing RA-related pain among older adults. Overall, the results of this study provide compelling evidence supporting the efficacy of foot massages in reducing pain intensity among older adults with Rheumatoid Arthritis. These findings highlight the potential of foot massages as a safe, accessible, and cost-effective adjunctive therapy for individuals grappling with the debilitating effects of RA-related pain. Nursing intervention and implementation Foot massages were implemented for 20 minutes daily over three days, alongside other nursing interventions tailored to each subject. The goal was to assess the impact of foot massages on pain intensity. Evaluation The pain scale assessments, conducted before and after foot massages, demonstrated a consistent decrease in pain intensity for both subjects, aligning with previous research (Muliani et al., 2019). Subjective data indicated improved sleep quality and com- fort for Mrs. L, who could independently engage in foot massages. Mrs. A, with external limitations, still reported reduced pain inten- sity but faced challenges in implementing foot massages indepen- dently.5 Discussion The results of this study demonstrate the efficacy of foot mas- sages as a non-pharmacological intervention for reducing pain intensity among older adults with Rheumatoid Arthritis (RA). The significant reduction in pain intensity observed following the foot massage intervention underscores the therapeutic benefits of this approach in managing RA-related pain. The findings align with prior research by Rindriani & Adriani (2022) and Muliani et al. (2019), which also suggested that foot massages may lead to a decrease in RA pain intensity. This consis- tency across studies further strengthens the evidence supporting the use of foot massages as a complementary therapy for RA pain management.4,5 The individual responses to the foot massage intervention highlight the variability in treatment outcomes among participants.7 While some participants experienced a more pro- nounced reduction in pain intensity, others exhibited a more mod- est response.8 This variability may be attributed to differences in individual pain thresholds, disease severity, and responsiveness to the intervention.9 Qualitative feedback from participants indicates a high level of satisfaction and comfort with the foot massage intervention.10 Participants reported improvements in joint mobility and overall well-being, suggesting that foot massages not only alleviate pain but also contribute to enhanced physical and emotional well- being.4 Article Table 1. Observation of subject I pain scale assessment before and after implementation. No. Date SUBJECT I KET Time Pain Scale Before Implementation Time Pain Scale After Implementation 1. 28 Maret 2023 13.00 5 13:30 4 Decreasing 2 29 Maret 2023 15:30 5 16:00 4 Decreasing 3. 30 Maret 2023 15:00 4 15:30 3 Decreasing Table 2. Observation of subject II pain scale assessment before and after implementation. No. Date SUBJECT I KET Time Pain Scale Before Implementation Time Pain Scale After Implementation 1. 01 April 2023 14.00 6 14:30 5 Decreasing 2 02 April 2023 14.30 6 15:00 4 Decreasing 3. 03 April 2023 14.30 5 15:00 3 Decreasing [Healthcare in Low-resource Settings 2024;12:12616] [page 611] Non -co mmerc ial us e o nly The high level of adherence and compliance observed among participants further supports the feasibility and acceptability of foot massages as a therapeutic intervention for RA-related pain. The absence of reported adverse effects highlights the safety of this approach, making it an attractive option for individuals seeking non-pharmacological alternatives for pain management . Limitations of this study include the small sample size and reliance on self-reported pain assessments, which may introduce bias into the results. Additionally, the short duration of the inter- vention limits the ability to assess the long-term effects of foot massages on RA pain management. Future research with larger sample sizes and longer intervention periods is warranted to address these limitations and provide further insights into the effi- cacy of foot massages for RA pain relief. Overall, the findings of this study contribute to the growing body of evidence supporting the use of foot massages as a safe and effective adjunctive therapy for managing RA-related pain. By offering a non-pharmacological approach to pain management, foot massages have the potential to improve the quality of life for individuals living with Rheumatoid Arthritis. Conclusions This study contributes valuable insights into the potential effi- cacy of foot massages in reducing RA pain intensity. The positive outcomes observed in this case study warrant further exploration through larger-scale research, emphasizing the importance of non- pharmacological interventions in RA management. References 1. Margaret RL. How common is rheumatoid arthritis ? 2022. p. 1–12. Available from: https://www.medicalnewstoday. com/articles/rheumatoid-arthritis-prevalence 2. Centers for Disease Control. Rheumatoid Arthritis. 2020. 3. RISKESDAS. Laporan Riskesdas 2018 Nasional.pdf. Lembaga Penerbit Balitbangkes. 2018. p. 156. 4. Rindriani D, Adriani P. Pemberian Terapi Massage Kaki Dalam Menurunkan Skala Nyeri Pada Lansia Rheumatoid Arthritis. 2022;3:5471–8. 5. Muliani RTSSN. Stimulasi Kutaneus (Foot Massage) Menurunkan Skala Nyeri Pasien Lansia Dengan Rheumatoid Arthritis Cutaneous Stimulation (Foot Massage) On Pain Scales In Elderly With Rheumatoid Arthritis. J Wacana Kesehat 2019;4(2). 6. WHO. Musculoskeletal Health. World Heal Organ 2022:1–5. 7. Hartatik S, Sari RP. Efektivitas Terapi Pijat Kaki. Nusant Hasana J 2021;1:26–36. 8. Ananda KS. 8 Manfaat mengejutkan dari pijat kaki [Internet]. Merdeka.com. 2015. Available from: https://www.merdeka. com/sehat/8-manfaat-mengejutkan-dari-pijat-kaki.html 9. Rhuito, F. Mahendra B. Pijat Kaki Untuk Kesehatan. 10. 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. J Chiropr Med 2018;17:182–9. Article [page 612] [Healthcare in Low-resource Settings 2024;12:12616] Non -co mmerc ial us e o nly