***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: PURPOSE This study was to examine the effects of self-foot reflexology on stress , fatigue and blood circulation in premenopausal middle-aged women . METHODS A quasi-experimental nonequivalent control group , pretest-posttest design was used . Participants were 59 premenopausal , middle-aged women in their 40s and 60s living in G city : 30 in the experiment group and 29 in the control group . Data were collected from May to August 2008 .  Self-foot reflexology was performed three times a week for 6 weeks for 40 min at each session . RESULTS The results showed that self-foot reflexology was effective in reducing perceived stress and fatigue and helped blood circulation in premenopausal middle-aged women . CONCLUSION Self-foot reflexology may be an effective nursing intervention in reducing perceived stress and fatigue and in improving blood circulation PURPOSE The purpose of this study was to evaluate the effects of self-foot reflexology on stress ( perceived stress , urine cortisol level , and serum cortisol level ) , fatigue , skin temperature and immune response in female undergraduate students . METHODS The research design was a nonequivalent control group pretest-post test design . Participants were 60 university students : 30 in the experiment group and 30 in the control group . The period of this study was from April to June 2010 . The program was performed for 1 hr a session , three times a week for 6 weeks . The data were analyzed using the SPSS/WIN 17.0 program . RESULTS The results showed that self-foot reflexology was effective in reducing perceived stress and fatigue , and raised skin temperature in female undergraduate students . But cortisol levels and immune response were not statistically significant different . CONCLUSION The results of this study indicate that self-foot reflexology is an effective nursing intervention in reducing perceived stress and fatigue and , in improving skin temperature . Therefore , it is recommended that this be used in clinical practice as an effective nursing intervention for in female undergraduate students PURPOSE This study was done to examine the effects of aroma self-foot reflexology massage on stress and immune responses and fatigue in middle-aged women in rural areas . METHODS The study was a nonequivalent control group pre-post test design . The participants were 52 middle-aged women from rural areas of which 26 were assigned to the experimental group and 26 to the control group . Data were collected from July to September , 2011 and analyzed using SPSS Win 17.0 version program . The intervention was conducted 3 times a week for six weeks . RESULTS There were significant differences in reported perceived stress , systolic blood pressure , diastolic blood pressure and fatigue between the two groups . However , the issue of salivary cortisol and immune response were not significant . CONCLUSION Aroma self-foot reflexology massage can be utilized as an effective intervention for perceived stress , systolic blood pressure , diastolic blood pressure and fatigue in middle-aged woman in rural areas Objective : To determine whether reflexology therapy — the application of manual pressure to reflex points on the ears , h and s , and feet that somatotopically correspond to specific areas of the body — can significantly reduce premenstrual symptoms compared to placebo treatment . Methods : Thirty-five women who complained of previous distress with premenstrual syndrome ( PMS ) were r and omly assigned to be treated by ear , h and , and foot reflexology or to receive placebo reflexology . All subjects completed a daily diary , which monitored 38 premenstrual symptoms on a four-point scale . Somatic and psychological indicators of premenstrual distress were recorded each day for 2 months before treatment , for 2 months during reflexology , and for 2 months afterward . The reflexology sessions for both groups were provided by a trained reflexology therapist once a week for 8 weeks , and lasted 30 minutes each . Results : Analysis of variance for repeated measures demonstrated a significantly greater decrease in premenstrual symptoms for the women given true reflexology treatment than for the women in the placebo group . Conclusion : These clinical findings support the use of ear , h and , and foot reflexology for the treatment of PMS Thirty-two depressed adolescent mothers received ten 30-minute sessions of massage therapy or relaxation therapy over a five-week period . Subjects were r and omly assigned to each group . Although both groups reported lower anxiety following their first and last therapy sessions , only the massage therapy group showed behavioral and stress hormone changes including a decrease in anxious behavior , pulse , and salivary cortisol levels . A decrease in urine cortisol levels suggested lower stress following the five-week period for the massage therapy group OBJECTIVES To develop and vali date a new risk-of-bias tool for nonr and omized studies ( NRSs ) . STUDY DESIGN AND SETTING We developed the Risk of Bias Assessment Tool for Nonr and omized Studies ( RoBANS ) . A validation process with 39 NRSs examined the reliability ( interrater agreement ) , validity ( the degree of correlation between the overall assessment s of RoBANS and Method ological Index for Nonr and omized Studies [ MINORS ] , obtained by plotting the overall risk of bias relative to effect size and funding source ) , face validity with eight experts , and completion time for the RoBANS approach . RESULTS RoBANS contains six domains : the selection of participants , confounding variables , the measurement of exposure , the blinding of the outcome assessment s , incomplete outcome data , and selective outcome reporting . The interrater agreement of the RoBANS tool except the measurement of exposure and selective outcome reporting domains ranged from fair to substantial . There was a moderate correlation between the overall risks of bias determined using RoBANS and MINORS . The observed differences in effect sizes and funding sources among the assessed studies were not correlated with the overall risk of bias in these studies . The mean time required to complete RoBANS was approximately 10 min . The external experts who were interviewed evaluated RoBANS as a " fair " assessment tool . CONCLUSIONS RoBANS shows moderate reliability , promising feasibility , and validity . The further refinement of this tool and larger validation studies are required 
    Output:
    
RESULTS Analysis of three non-r and omized trials and three before- and -after studies showed that self-administered foot reflexology result ed in significant improvement in subjective outcomes such as perceived stress , fatigue , and depression .
However , there was no significant improvement in objective outcomes such as cortisol levels , blood pressure , and pulse rate .
This study presents the effectiveness of self-administered foot reflexology for healthy persons ' psychological and physiological symptoms .
While objective outcomes showed limited results , significant improvements were found in subjective outcomes .