Like it or not, health farms and lifestyle supplements have stamped reflexology's image as a 'toe-twiddling' indulgence for stressed professionals.
'It's fair enough, if that's how people want to use it, but we use it very specifically,' says Ann Childs, a lecturer practitioner at Nottinghamshire Mental Health trust and one of a growing number of physiotherapists keen to shrug off the therapy's ditsy image.
She acknowledges the challenge in putting across a more representative picture, adding: 'It's a subject that can soon become very fluffy and not say anything. But it is actually a bone fide clinical therapy to be used within clinical situations by health professionals.
Another physiotherapist, Jenny Lee, who uses the technique to treat children with asthma, agrees, saying: 'Reflexology is not a homely little treatment, it's not just massage or stress relief.'
And Kate Gardner, a physio using reflexology to help people with obesity, suggests its profile can change: 'I think we are where acupuncture was some years ago. Now acupuncture is a recognised way for treating pain. We would like to integrate reflex therapy into the NHS,' she told Frontline.
Developed centuries ago in countries such as China, Egypt and India, reflexology is often referred to as a 'gentle' and 'holistic' therapy that benefits both mind and body.
It centres on the feet because these are said by practitioners to be a mirror, or topographical map, for the rest of the body.
Manipulation of certain pressure, or reflex, points is claimed to have an effect on corresponding zones in the body. The impact, say reflexologists, extends throughout - to bones, muscles, organs, glands, circulatory and neural pathways. The head and hands can also be massaged in some cases.
The treatment is perhaps best known for use in connection with relaxation and relief from stress, anxiety, pain, sleep disorders, headaches, migraine, menstrual and digestive problems.
But advocates say it can be used to great effect far more widely, often in conjunction with other treatments.
'It has value in every area, but its added value is that you can use it where other traditional physiotherapy approaches aren't appropriate,' says Ann Childs.
She's been using reflexology for 25 years and includes it in 'the majority' of her 'patient contacts'.
Her patients have included children with severe learning difficulties and older people with dementia. She says reflexology has particular value in 'abuse' cases 'where touch is difficult'.
'If you're treating a spinal problem and the patient doesn't want to be physically touched on the body, you can work through the feet,' says Ann.
She finds reflexology 'particularly effective' for mental health problems such as panic attacks, anxiety, depression, psychosis.
Sessions can last from two minutes to an hour and the treatment is always adapted to the person's needs.
It can be used, Ann says, as a 'safe starter' procedure, to build communication with patients in troubled mental states and to improve practitioner-patient confidence. 'In mental health, a patient may come in with a back problem, or a knee problem, for example, but alongside that is always anxiety, depression, low self-esteem. So you're actually acknowledging those issues together.'
Ann continues: 'I feel quite strongly about using it in mental health, because it's so effective - and there are so very few other treatments that are as effective - in addressing and integrating the body-mind issues.'
According to the Association of Reflexologists (AoR), reflexology 'works' by releasing blockages and restoring the 'free flow of energy to the whole body'. By detecting tiny deposits and imbalances in the feet, reflexologists can ease tensions, allowing the body 'to heal itself, often counteracting a lifetime of misuse,' says the AoR.
But this has not been scientifically proven. As Ann concedes: 'Nobody really understands how it works. There have been lots of hypotheses. Now we're looking more at neural mechanisms, but people have looked at quantum physics, energy medicine, at resonance with tissuesÉ There's a lot of hypotheses but at this moment in time there's no definitive understanding.'
The lack of evidence is clearly not helpful for practitioners, including the many chartered physiotherapists who have in-depth training in the skills of massage and manipulation and who are seen as particularly suited to peforming reflexology.
Some 200 physios are members of the CSP clinical interest group ACPIRT, the Association of Chartered Physiotherapists in Reflex Therapy.
Gunnel Berry, a spokesperson for the group, told Frontline: 'We are keen to raise the profile of reflexology among our fellow physiotherapists and the public to make it known that we are a serious lot.'
But she admits that reflexology is considered less 'evidenced' than other complementary therapies such as acupuncture, homeopathy and osteopathy: 'To date, the evidence for efficacy of treatment is, in the main, retrospective observations of patients' outcomes.'
But Gunnel says longitudinal studies are 'on their way', adding: 'A growing number of people involved in various health settings are starting to emerge with results suggesting a positive link between therapy and outcome. Areas of particular note include respiratory, mental health, general health issues like obesity, and musculoskeletal issues.'
Gunnel uses reflexology to help patents with spinal pain and whiplash injury, both in the private sector and in the NHS, at the Chase Hospital in Bordon, Hampshire.
She says: 'My observations suggest that the therapy affects the autonomic as well as the voluntary systems including control of movement. I have observed different responses in acute or chronic states where pressures of contact have to be accommodated accordingly.'
Among the observed benefits of treatment, Gunnel cites 'changes in joint movements, muscle strength and functional activities'.
She adds: 'The strength of reflexology is in its non-invasive nature and often, quick and good response rate.'
The treatment can be effective, she says, whatever the age or gender of patients, and leads to 'a high degree of patient satisfaction'.
Gunnel, also an AoR member, presented papers on reflexology at last year's World Confederation for Physical Therapy congress in Barcelona.
She believes wider recognition, however ('especially in the NHS'), will depend on carrying out randomised controlled trials (RCTs) to support or refute reflexology's efficacy.
She told Frontline: 'I would like to see funding allocated for research in reflexology, especially in those areas which anecdotally are of such great immediate value to the patients, such as asthma sufferers, pain sufferers, mental health-like anxiety states.'
Meanwhile, Jenny Lee is preparing to carry out a large clinical trial in the UK of reflexology treatment for children with asthma. Training practitioners, including physios, is under way.
She says small pilot studies carried out in the 1990s and involving around 50 primary schoolchildren showed reflexology dramatically reduced asthma symptoms and led to reduced levels of medication.
'Asthma is a complex disease and different triggers set it off, including stress,' she told Frontline. 'Reflexology treatment is kinder on children than acupuncture, not as uncomfortable or as offputting, and can be given safely with the child's prescribed medication.'
Jenny, who is an honorary member of the AoR and member of ACPIRT, has approached the National Asthma Campaign for funding. She hopes to start the larger clinical trial later this year or early next, involving at least 250 children.
'We have to do thorough research before doctors will take any notice,' she says. So far, ACPIRT has supported the trial with a GPB 500 grant for a training film.
Keen to raise awareness of reflexology among physios, Jenny adds: 'I think a lot of physiotherapists don't know about the work we're doing. A lot of young people coming into physiotherapy would like perhaps to take up reflexology but they don't really know much about it. If they know there's something as important as what we've being doing they might think it's a good idea.'
Kate Gardner devised a physiotherapy-led programme using reflexology alongside exercise for severely obese NHS patients in the Merseyside health action zone.
She told Frontline: 'A physio can apply it to any area he or she uses any other treatment for. Some of us use it as a first treatment, or as an alternative technique for someone not responding to other treatment.'
Kate says an evaluation of her project, which used an exercise circuit programme 'based on the cardiac rehab style' for adults attending a weight management clinic, found it brought substantial benefits to patients.
Kate has been invited to visit the US this month to demonstrate the integrated health programme to a conference on Alstrom Syndrome, a rare genetic condition which affects children and can result in conditions such as obesity and diabetes.
'The aim of the session will be to do really practical activity - exercises, breathing exercises, complementary and other techniques including reflex therapy. These can all be done at home with little or no equipment. It's great.'
Kate aims to publish a study on the project in a clinical journal to contribute to the developing research base.
Ann would also like to see more research, including a broader qualitative review of reflexology treatment. 'There's a problem with all the studies that I've seen so far - they're not the gold-standard RCTs - which is one of the reasons why it's not been taken on board.
'The problem with reflexology is that it doesn't fit nicely into a gold-standard RCT. There need to be other ways of evaluating its effectiveness, and the meaning to the patient.'
Ann continues: 'It's difficult to identify the correct outcome measure, and that's come up time and time again when we've had discussions about the way forward.'
The UK's only professor of complementary therapies, Edzard Ernst, rejects the view that holistic, individualised treatment approaches like reflexology can't be 'squeezed' into the RCT format.
Professor Ernst, of the Peninsula Medical School, Universities of Exeter and Plymouth, told Frontline: 'Methodologically it is not difficult to do the trials, but the problem is lack of money. It's hardly ever a priority area. Research money is very short. Reflexology doesn't make that priority.'
'I think many people still think it's a bit of toe-twiddling,' says Kate.
And Jenny observes: 'We've got to get research done, otherwise we'll not be taken seriously.'
For more information about reflex therapy, please contact ACPIRT public relations officer Caroline Jackson. Tel: 0167 2515700, email: firstname.lastname@example.org