The author is a physiotherapy clinical specialist in the treatment of chronic and acute pain, who was offered an opportunity, in 1999, to participate in a pilot study of physiotherapy for patients with whiplash injury in a general medical practice (Tobin 2000). Having also studied and practiced generic reflexology for many years, a coincidental event occurred at this time, in which she observed a demonstration of reflexology, using only a single point of application on the feet to achieve a change in symptoms. This caused her to question and challenge her reflexology practice and to consider new ways of working, which resulted in the development of a new style of treatment with its own techniques, working hypotheses and applied clinical reasoning.

Pain, especially chronic pain, is a common reason for physiotherapy referral. Chronic pain affects 15–20% of the population in the United States (Stephenson & Dalton 2003) and one in five adults in Europe (Breivik et al. 2005). It is reported that 20% of all whiplash-injured patients still suffer painful states 6 months after the injury occurred (Malanga and Nadler, 2002 and Chien and Sterling, 2005), and to date there is no known therapy which has proved reliably effective for improving symptoms of patients suffering from chronic disability.

Many physiotherapists use reflexology or reflex zone therapy; the term ‘reflextherapy’ was adopted in 1992 by the Association of Chartered Physiotherapists in Reflextherapy (ACPIRT). This reflects the therapeutic intention of the therapy within physiotherapy practice, as well as embracing the variety of reflexology approaches available. Adapted Reflextherapy (AdRx) is a task-specific, manual, topical, stimulation of short duration to the feet according to the principles of reflexology but with reasoned aspects of neurogenic adaptation in painful states (Berry 2007a). AdRx is practiced according to established standards for physiotherapy practice (Core Standards 2005), including patient consent, assessment and treatment cycle and documentation of outcomes. AdRx has been used to treat patients of all age groups with acute and chronic pain states and has proved particularly effective in reducing hypersensitivity in whiplash-injured patients. Over 200 professionals have been trained to use AdRx in their own work, indicating its transferability across other disciplines.

AdRx uses the original theory of reflexology as a basis to identify areas on the feet which correspond to other parts of the body. However, while reflexology treatment encompasses the whole foot and is intended to be a general health stabilisation technique, AdRx is very specific and seeks out those areas which are specifically relevant to the patient’s presentation. Since many physiotherapy patients have musculoskeletal problems, frequently with spinal involvement, and some neurological compromise, AdRx is performed primarily on the reflex zones for the spine. In accordance with most reflexology charts, the area of the spine is represented on the medial longitudinal arches of the feet beginning at the calcaneum representing the sacrum and coccyx, the navicular and cuboid bone representing the lumbar spine and the first metatarsal bone representing the thoracic spine. The cervical spine is represented on the proximal phalanx of the big toe with the right foot representing the right half of the spine and the left foot representing the left half. Foot examination and treatment is convenient and provides a quick overview of the whole spine; frequently, areas of stiffness or tenderness are found in the foot, which, from reflextherapy theory, indicate compromise of spinal structures.

Adapted Reflextherapy is used in physiotherapy practice to assess and treat patients of any age who are suffering from some form of pain or discomfort, especially those suffering whiplash-associated disorder (WAD). A whiplash injury is ‘an acceleration and deceleration mechanism of energy transfer to the neck’ (Hartling et al. 2001), most frequently caused by a road traffic accident, although similar trauma may occur in any situation where the head and neck are exposed to sudden acceleration–deceleration motions (Barnsley et al. 2002). The sudden, rapid change of direction in the movement of the head and neck results in hyperflexion and hyperextension. Fifty per cent of patients with whiplash injury recover within 3 months without the need for medical treatment (Malanga & Nadler 2002); 27% recover in 6 months, but 19–23% are still suffering symptoms after 1 year (Chien & Sterling 2005). There appear to be some adapted central nervous system processing mechanisms at work which assist recovery (Chien et al. 2008), but there is currently no guaranteed effective treatment for those with long-term problems (Atherton et al. 2006). AdRx may be used as the only method of treatment or, more often, in conjunction with other modalities. Most patients referred for treatment of WAD attend between four and six sessions.

Adapted Reflextherapy is undertaken only after a careful assessment of the patient’s previous medical history and assessment of the physical and psychological aspects of the pain. There are few contraindications to the use of AdRx: the ACPIRT advises that patients in whom AdRx is inappropriate include those with malignant melanoma; deep vein thrombosis, phlebitis, venous and/or lymphatic inflammation; transplants of heart, kidney or other organs; acute infectious diseases; at risk of ectopic pregnancy; syncope after commencing treatment; known epilepsy; any other concerns regarding medical or behavioural symptoms.

As with conventional reflexology, strict precautions should be applied to patients with neurological disturbance, acute metabolic diseases, first-trimester pregnancy, AIDS and immunosuppressive conditions, psychotic disturbance and schizophrenia, contagious diseases, peripheral vascular disease, tuberculosis or suspected symptoms and diabetes mellitus. Medication may inhibit adverse reactions to therapy; therefore, caution should be exercised in patients who are persistent drug abusers or who are taking prescribed medications, particularly slow-release or long-term medication, e.g. hormone replacement therapy, thyroxine, insulin and antihypertensives.

Adapted Reflextherapy is only applied following a full physiotherapy assessment conducted by a qualified physiotherapist trained in this particular technique. AdRx assessment is incorporated into this process, including a full history of any past road traffic accidents, falls and mishaps, even those which occurred a long time ago and have been almost forgotten. Even minor incidents may have an effect on the neural system, causing neural adaptation (Greening 2006) whilst peripheral inputs will alter the nociceptive afferent barrage proposing an ongoing alteration of the central processing effect (Gracely et al., 1992 and Coderre et al., 1993). Sympathetic nervous pathways appear to have a role to play in maintained pain patterns, yet, can also be independent of that pathway, but either may have an accumulative effect (Butler and Moseley, 2003 and Coderre et al., 1993) due to a new gene expression, which may be just the ‘tip of the iceberg’ in the present pain presentation. The assessment process also includes any history of major operations and possible scar formation of fascial structures, dental changes, jaw reconstructions however seemingly insignificant at the time, but which may have a role to play in the current pain presentation. Clinical observations suggest that, in the main, most episodes of unknown pain patterns have an origin of compromise in the neuromusculoskeletal chain, possibly dating back beyond the present clinical presentation and beyond the patient’s own recall of such events, although these assumptions are difficult to prove.

Research has shown that the impact of trauma on the body may develop into post-traumatic stress disorder (PTSD) (Rothschild 2000). PTSD includes chronic hyperarousal of the autonomic nervous system (ANS) in addition to ‘flashbacks’ and avoiding reminders of the trauma. Patients seen in everyday physiotherapy departments may not be diagnosed with PTSD but they may nevertheless have a very minor tendency towards the same neurological pattern of events, which may influence existing pain patterns. The basis of this theory is that increased pain-producing peptide levels are found distally from the primary source of injury in vitro (Eliav et al. 1999) and in vivo after trauma (Guez et al. 2003).

Following the history taking, a physical examination of the whole spine and lower limbs is undertaken, even if the WAD symptoms are located in the shoulder and neck region. Other issues, such as posture compromise (e.g. scoliotic changes), muscle bulk imbalances, leg length difference, circulatory insufficiencies, outcomes of other treatments, shingles and invasion of foreign bodies (tics, wasp stings) can easily be identified and may be relevant to AdRx treatment. This is followed by examination of the feet to elicit further information related to possible areas of compromise in the body. Findings from the physical examination are discussed with the patient. If the patient agrees, the treatment can commence.

Adapted Reflextherapy treatment is applied as pressure to the feet, or hands if appropriate, using five handhold techniques. The five handhold techniques are: ‘walking’, with intermittent pressure and release, to identify stiff segments; three-point AdRx, using three points of contact on the medial arches of the foot as part of the treatment procedure; spine zone twisting, to aid assessment and treatment; linking, in which pressure is simultaneously applied to two or more points on the feet, similar to the linking used in precision reflexology (Williamson 1999); and a technique called ‘thru/thru’, another form of partial linking, which has been seen to ease thoracic spine stiffness and involvements of the ribs and myogenic structures associated with the ribs and intercostal nerve impingement.

Interpretation and identification of the feet structures are compared with the patient’s clinical presentation and whether it has any clinical relevance. Tactile pressure on sensitive areas on the feet produces pain, which affirms the afferent connection to higher centres. Sporadically, the patient reports sensory changes during treatment episodes such as ‘warmth’, ‘tingling’, ‘pain running up my leg’, ‘a funny sensation in the leg’ (formication), ‘prickling in the back’ and lightheadedness. This is a further confirmation of neural involvement suggesting an autonomic nervous system reaction. Whether this is an increase of the sympathetic component of the ANS is speculative. See Sterling and Kenardy (2006) for a discussion of the relationship between post-traumatic stress reaction (PTSR) and sympathetic nervous system changes in whiplash injury. The outcome of the treatment frequently results in an increased (cervical) range of spinal movement and peripheral joint movement in correlation to which area has just been treated. Increased straight leg raising mobility is also frequently noted.

Patients suffering from WAD who do not recover from their symptoms often present with central hypersensitivity tissues (Curatolo et al. 2001) and show widespread mechanical hyperalgesia (Scott et al. 2005), independent of any anxiety, which may indicate poor prognosis (Sterling & Jull 2003). Hypersensitivity is a neurological phenomenon indicating abnormal responses to a normal stimulus that would not usually evoke a response. Some trauma may create hyperalgesia after minor nerve injury with no obvious signs of nerve damage (Greening 2001). The nervi neuorum can become spontaneously active and mechanically sensitive after injury (Greening 2006), and the axonal flow may contain traces of inflammatory cells (Eliav et al. 1999) indicating peripheral involvement in damaged nerve tissue and immunological changes (Marchand et al. 2005). Multiple body systems are activated to respond to the ‘fight or flight’ situation triggered by injury and pain, including the autonomic nervous and endocrine systems (Van Griensven 2005), and there is an increased probability of immune-cell signalling after peripheral nerve injury which feeds abnormal nociceptive inputs into the dorsal root ganglion (Saab & Hains 2008). Melzack and Wall (1991) introduced the concept of ‘plasticity’ of the nervous system and suggested that the inter-related activity demand and reaction in the nervous system as a whole reacts, protects and repairs itself in adverse conditions. In AdRx, pressure on the skin is adjusted according to irritability of the tissues. High irritability tissue symptoms require light touch of short duration, which is frequently used in acute inflammatory conditions directly after trauma. Low irritability, as seen in more chronic conditions, necessitates deeper pressure of longer duration being applied to the skin. AdRx treatment is performed with the patient supine to enable the practitioner to assess straight leg raise testing as treatment progresses.

The early findings of Ingham in 1938 (Ingham 2005) of a correlation between sensory endings on the feet and the soma are supported in contemporary clinical practice by reflexology and reflextherapy practitioners (Quinn et al. 2008), and AdRx has been well justified by conscientious documentation of patient responses and the effectiveness of treatment (Berry, 1999, Berry, 2003 and Berry, 2007). Although the inter-relational interpretation and mechanism of action is inconclusive (Tiran & Chummun 2005) this should not exclude the possibility of verification at a later stage. Whilst speculation over the mechanism of action continues, clinical demand for action to improve patients’ painful conditions is unrelenting. The ultimate challenge in clinical practice is how to impart a coding system into the physical body which can break the reactive hardware system which has reacted quite naturally to a ‘fight and flight’ situation.

AdRx may produce counter-irritability whereby the CNS, including the autonomic nervous system, has to react to peripheral tactile sensory stimulus. During AdRx the quantity and quality of neurotransmitters within the neural axonal content change, a phenomenon which has been shown during stroking applications in general massage (Lund et al. 2005) although the mechanism for this is purely speculative. Clinical observations suggest that AdRx facilitates a diagnostic element in addition to effects of the treatment itself, although assessment and identification of tender areas on the feet is undertaken as part of the total physical assessment of the patient. Importantly, physical findings are compared and reasoned before treatment commences.