Leg-foot chest compressions: a scoping review

Graphical abstract

Abstract

Objectives

High-quality chest compressions (CCs) are vital for the return of spontaneous circulation. When hand CCs are difficult, leg-foot CCs may offer an alternative. We reviewed existing studies to describe the current evidence and identify gaps in the literature regarding this technique and its impact on outcomes.

Methods

Between November and December 2024, we conducted a scoping review, searching eight databases, two proceedings (Resuscitation 2024 and the Resuscitation Science Symposium 2024), a trial register, animal guidelines, citations, and reference lists. We included studies on leg-foot CCs performed on humans, animals, or manikins by laypersons, healthcare professionals, pre-licensure students, or duty-to-respond laypersons. The intervention was leg-foot CCs; the comparison was standard hand CCs. Outcomes were feasibility, acceptability, and effectiveness (rate, depth, recoil, location). Eligible designs included trials, non-randomised studies, case reports, and research letters with English abstracts from 1960 to 2024.

Results

Out of 1173 records, we identified 14 studies comparing leg-foot and hand CCs, all using manikins, mostly from Western countries (11/14 studies). No human studies were identified. Twelve compared depth, nine rate, six recoil, and eight location. Most studies found no significant subgroup differences, though some reported better performance in heavier participants or when using a balance aid. Several studies observed differences in rate, recoil, and location overall. Of five studies assessing fatigue, two favoured leg-foot CCs, one was mixed, and two favoured hand CCs.

Conclusion

No human studies of leg-foot CCS were identified. On manikins, leg-foot CCs are feasible and may reduce fatigue, but results vary. More research, including animal or human studies, is needed.

Introduction

High-quality chest compressions (CCs) are one of the key parameters associated with survival outcomes for cardiac arrest patients. They are defined by appropriate compression rate and depth, full chest recoil after each compression, correct position of the hands, and a low rate of interruptions.1, 2, 3 Due to the emphasis on minimizing interruptions during cardiopulmonary resuscitation, the 2021 European Resuscitation Council (ERC) adult basic life support (BLS) guidelines state that rescuers should not interrupt cardiopulmonary resuscitation (CPR) until: a health professional instructs them to stop, the person is definitely waking up—moving, opening their eyes, and breathing normally, or they become physically exhausted.²

Given the emerging challenges in CCs delivery—such as rescuer fatigue,⁴ decreasing physical strength over time and disability,5, 6, 7, 8, 9 confined or hazardous environments, and concerns over infection transmission during pandemic—there has been renewed interest in alternative CCs techniques,10, 11, 12 including leg-foot CCs.

Although the first study on leg-foot CCs was published in 1987,¹³ the technique did not gain significant attention until it was referenced in the 2005 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science and Treatment Recommendations (CoSTRs).¹⁴ However, due to the limited number of studies on that technique that time and lack of human studies, no treatment recommendation was issued. Notably, the technique has not been reviewed or included in any subsequent ILCOR CoSTRs.17, 18 Therefore, we conducted a scoping review to synthesize available evidence on leg-foot CCs, clarify their feasibility, acceptability, and effectiveness, and identify gaps in the literature.

Methods

The scoping review was carried out using the methodological framework outlined by Levac et al.,¹⁹ and the reporting adhered to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist (Supplementary appendix 1).²⁰ The protocol for the review has been registered on OSF Registries and is accessible via its DOI: 10.17605/OSF.IO/9KPJ4²¹ (Supplementary appendix 2).

Eligibility criteria

The research question was structured using the Population/Participants, Intervention, Comparison, Outcomes, Study design, and Timeframe (PICOST) framework:

Population/Participants: Any patient (neonatal, paediatric, or adult), animal (small, large) or manikin on whom leg-foot CCs were performed by rescuers (laypersons, healthcare professionals, pre-licensure students and duty-to-respond laypersons) who administered leg-foot CCs on patient (neonatal, paediatric, or adult), animal or manikin. Laypersons were defined as individuals without a healthcare degree (e.g., schoolchildren or schoolteachers), healthcare professionals such as those with a healthcare degree (e.g., registered nurses or physicians), pre-licensure students as individuals currently pursuing a healthcare degree (e.g., nursing or medical students), and duty-to-respond laypersons as those without a healthcare degree but with a responsibility to respond in emergencies (e.g., firefighters or lifeguards).

Intervention: The leg-foot CCs refers to performing CCs using either the heel, ball of the foot, or entire foot to deliver force to compress the chest.

Comparison: The hands CCs involves placing the heel of one hand in the centre of the chest on the lower half of the breastbone, with the heel of the other hand positioned directly on top. Fingers should be lifted or interlocked to keep them off the chest.1, 2, 3

Outcomes: We define two main outcomes: 1) Feasibility and acceptability, which encompasses the practical and implementation aspects of the leg-foot CCs, including training feasibility, and physical feasibility, and 2) Effectiveness of the leg-foot CCs, in the form of high-quality CCs parameters: rate, depth, recoil, and location1, 2, 3 performed on a patient, animal, or manikin. Although patient outcome was prospectively designated as an outcome of interest, (e.g., return of spontaneous circulation, survival to hospital discharge or 30 days, one-year survival, or survival with favourable neurological outcome), no human studies were identified to address this outcome.

Study design: Randomized controlled trials, nonrandomized (controlled) studies trials, cross-sectional studies, cohort studies, case-control studies, case reports/series, and research letters were eligible for inclusion.²² Reviews, conference abstracts, registered trials, editorials, letters to the editor, and notes were excluded manually or using search hedges and/or removed during screening. All relevant publications in any language were included if an English abstract was available.

Timeframe: January 1, 1960 – December 3, 2024. An additional update search was performed on July 15, 2025, to include studies published between December 4, 2024, and July 15, 2025.

Search strategy

The search strategy was constructed by a medical research librarian (KM) with input from the primary investigator (NF) on December 3, 2024, and on July 15, 2025. The search strategy was also peer-reviewed by another medical research librarian. We searched the following bibliographic databases: Embase via embase.com, PubMed/Medline via the National Institutes of Health, Scopus via scopus.com, Web of Science via webofscience.com, CINAHL via EBSCO, Cochrane Library via cochranelibrary.com, ERIC via EBSCO, and PsycINFO via ProQuest. The following components were included in the search strings: Controlled terms: (MeSH, EMTREE), keywords, and search filters (Supplementary appendix 3).

We also manually searched abstracts from two major resuscitation science conferences, the ERC Resuscitation 2024 and American Heart Association (AHA) Resuscitation Science Symposium 2024.23, 24 This search was conducted by two authors (NF and ŠM) by using search function and keywords “leg”, “foot”, “ball of the foot”, and “heel”. The aim was to identify relevant studies and contact the corresponding author if their content met the PICO criteria (study design and timeframe here was not followed) to obtain further information regarding the future publication of the original study. Additionally, we manually searched the references of the included studies retrieved from the above-mentioned bibliographic databases, as well as their citations in Google Scholar. Furthermore, we reviewed the RECOVER (Reassessment Campaign on Veterinary Resuscitation) guidelines, which provide evidence-based recommendations for CPR in both small and large animals, to identify any mention of leg-foot CCs.25, 26 We manually screened Clinicaltrials.gov (trial registry) by using the keywords “chest compressions”, “leg”, “foot”, “ball of the foot”, and “heel”.

Study selection, data charting, synthesis, and presentation

All records were imported into the Rayyan Intelligent Systematic Review platform (Qatar Computing Research Institute, Doha, Qatar),²⁷ where duplicates were manually removed (NF). Next, two authors (NF and EDŠ, and NF and ŠM for the updated search) independently screened the studies based on the title or abstract or both following PICOST criteria. In cases where an abstract was not uploaded to the Rayyan Intelligent Systematic Review platform, but the title aligned with the inclusion criteria, the record was still selected for full screening. Full texts of the selected records were manually downloaded, saved and added into Rayyan Intelligent Systematic Review platform (NF). The final screening of full texts was conducted by the same authors (NF and EDŠ) also in the Rayyan Intelligent Systematic Review platform. In cases of disagreement, a third author (ŠM) was consulted.

Four researchers (NF, ŠM, RG, and TH) independently extracted and charted data using a standardized form in Microsoft Excel 365 (Microsoft Corporation, USA).²⁸ Discrepancies were resolved through discussion. The extracted data were then synthesized descriptively and summarized in tables.

Results

Study selection

The study selection process is summarized in the PRISMA flowchart (Fig. 1). Our search retrieved 303 references from databases and 920 from manual searches. After removing 131 duplicates, 165 references remained for title and abstract screening, which resulted in the exclusion of 150. Consequently, 15 articles underwent full-text assessment, with five excluded due to incorrect publication type.29, 30, 31, 32, 33 Additionally, we identified four relevant articles through manual search. From this search we also contacted a research team whose study aligned with our PICO framework and was presented at ERC congress Resuscitation 2024³⁴; however, their work is still in progress, and results are not yet available. Additionally, a manual screening of ClinicalTrials.gov (trial registry) identified one registered study³⁵ and no ongoing or future registered trials related to this topic. In January and March 2025, at the time we finalized the manuscript, an additional two studies had been published and found by manual screening using Google Scholar “recommendation article” feature,35, 36 bringing the total to 14 studies.13, 15, 16, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45 The additional update search did not identify any new eligible studies (Supplementary appendix 4).

Fig. 1.

PRISMA flow diagram of studies selection.

Study characteristics

All included studies were conducted in simulation environments using manikins. We did not find any human patient studies. The RECOVER guidelines did not contain any recommendations or references to leg-foot CCs for either small or large animals.25, 26

The included studies span from 1978 to 2025, originating from Europe,15, 16, 36, 38, 43, 44 North America,13, 37, 39, 41, 42 and Asia.35, 40, 45 Most studies were published in English,13, 35, 36, 37, 38, 39, 40, 42, 43, 44, 45 with a few in German15, 16 and Spanish.⁴¹ Based on the hierarchy of evidence,²² the studies ranged from non-randomized designs13, 15, 16, 37, 44, 39, 40, 41, 42 to prospective and crossover randomized controlled trials.35, 36, 38, 43, 45 The populations/participants studied varied, including laypersons,42, 45, 37, 38, 39 pre-licensure students,13, 35, 36, 41, 43 healthcare professionals,40, 44 duty-to-respond individuals,¹⁶ and mixed groups.¹⁵ The studies included 738 participants,13, 15, 16, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45 with sample sizes ranging from 20 to 121. Most studies35, 36, 45, 39, 40, 41, 42, 43 reported sex, showing more females (n = 293) than males (n = 170) with female representation ranging from 44 %⁴¹ to 65 %.³⁶ Participant ages (12/14 studies) ranged from 8 to over 80 years.13, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45

All studies compared leg-foot CCs to hand CCs.13, 15, 16, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45 Study conditions varied in CCs duration: two minutes,35, 38, 40, 42, 43, 44, 45 five minutes,13, 16, 36, 37 ten minutes,³⁹ and twelve minutes.¹⁵ One study compared a fixed number of CCs (200 CCs by hand vs. foot).⁴¹ Rest periods also differed: none,³⁶ ≥2 min,40, 43 ≥5 min,13, 42, 44 10 min37, 39, 45 and 30 min,³⁵ while four studies15, 16, 38, 41 did not report rest durations (Table 1).

Table 1.

Overview of included simulation studies.

Study (1st author surname, 1st author country, year), study type	Population/participants (number, previous experience in adult BLS training, gender, age)	Intervention and/or comparisons	Conclusion
Bilfield, Regula, 1978,13 (USA), non-randomised manikin study	20 pre-licensure (medical) students, no previous experience in adult BLS training data, no gender data, aged 19 to 34 years.	Pretrial: Instructions and manikin practice. Trial: Five minutes of hands CCs for lighter weight group (n = 10) and 5 min of leg-foot CCs (n = 10). Five minutes rest between both techniques.	Favors the leg-foot CCs, as it resulted in fewer misplaced compressions and allowed weaker rescuers to achieve the proper compression depth.
Donegan, 1979,37 (USA), non-randomised manikin study	20 laypersons (adults and schoolchildren), eleven of which were trained in adult BLS knowledge, no gender data, aged 11 and 12 years for schoolchildren and 25–45 years for adults.	Pretrial: Demonstration and manikin practice. Trial: Five minutes of hands CCs for lighter weight group (n = 10) and 5 min of leg-foot CCs (n = 10). Ten minutes rest between both techniques.	Favors no specific technique, as there were no significant differences in compression effectiveness. However, the leg-foot CCs were preferred by lightweight rescuers and those performing prolonged compressions, while CPR-certified rescuers favoured the hands technique for better control.
Sefrin, Albert, 1979,15 (Germany), non-randomised manikin study	25 laypersons, without adult BLS knowledge, and 25 healthcare professionals, no gender and age data.	Pretrial: Brief instruction, no manikin practice. Trial: Twelve minutes of hands CCs and twelve leg-foot CCs (n = 25). Rest between both techniques was not mentioned.	Hands CCs was preferred to leg-foot CCs with was more exhausting and compression point hard to find and keep. Also, there was more pain in leg-foot CCs.
Jost, 1980,16 (Germany), non-randomised manikin study	60 duty-to-respond laypersons, no previous experience in adult BLS training data, no gender and age data.	Pretrial: Not mentioned if instructions were given. Trial: Five minutes of hands CCs and five minutes of leg-foot CCs (n = 60). Rest between both techniques was not mentioned.	The leg-foot CCs do not offer any special advantages over the hands CCs if the helper is tired; nor is it easier to learn.
Kherbeche, et al., 2015,38 (Switzerland), prospective, randomized, controlled manikin study	105 laypersons (schoolchildren), none of which had previous BLS knowledge, no gender data, aged between 10 and 15 years.	Pretrial: Instructional video and manikin practice. Trial: Two minutes of hands CCs (n = 52) versus 2 min of leg-foot CCs (n = 53). Rest between both techniques was not mentioned.	Favors the hands CCs, as it resulted in better compression frequency, full decompression, and no advantage of the leg-foot CCs in achieving proper compression depth.
Trenkamp, Perez, 2015,39 (USA), non-randomised manikin study	49 laypersons (adults), 23 females/26 males, participants, no previous experience in adult BLS training data, no gender, aged between 35 more than 80 years old.	Pretrial: No structured practice reported. Trial: Ten minutes of hands CCs and ten minutes of leg-foot CCs (n = 49). Ten minutes rest between both techniques.	Favors the leg-foot CCs, as it allowed more than three times as many participants to sustain 10 min of compressions compared to the hands CCs, with significantly better endurance, especially for females.
Takahashi, et al., 2018,40 (Japan), non-randomised manikin study	21 healthcare professionals, with adult BLS knowledge, 10 females/11 males, and 33.6 ± 9.3 years.	Pretrial: Instructions on technique, but no practice on a manikin mentioned. Trial: Two minutes of hands CCs, 2 min leg-foot CCs, and 2 min of leg-foot CCs with footstool (n = 21). Ten minutes rest between both techniques.	Favors the leg-foot CCs with footstool, as it resulted in significantly deeper chest compressions and lower rescuer fatigue, making it a suitable alternative for smaller or fatigued rescuers.
Cairol Barquero, et al., 2019,41 (Costa Rica), non-randomised manikin study	34 pre-licensure (medical) students, no previous experience in adult BLS training data, 15 females/19 males, age 21.82 (CI 95 %: 21.1–22.5; MIN = 18 and MAX = 27) years.	Pretrial: Instructions on technique, but no practice on a manikin mentioned. Trial: Two hundred hands CCs and then 200 leg-foot CCs (n = 34). Rest between both techniques was not mentioned.	There was no significant in hands and leg-foot CCs depth and frequency since both were kept within the quality parameters.
Lau, Yamamoto, 2021,42 (USA), non-randomised manikin study	57 laypersons (schoolchildren), 22 of which had adult BLS knowledge, 38 female/19 males, and age 19.2 (±13.5).	Pretrial: Instructional video and manikin practice. Trial: Two minutes of hands CCs, 2 min of leg-foot CCs (jumping) while holding a stabilizing bar, and 2 min of squat-bouncing on the chest (n = 57). Five minutes rest between all three techniques.	Favors alternative compression techniques (leg-foot CCs jumping and squat-bouncing), as they allowed small resuscitators (<40 kg) to achieve sufficient compressions when the hands CCs were ineffective.
Otero-Agra, et al., 2021,43 (Spain), randomized simulation crossover manikin study	65 pre-licensure (nursing) students with adult BLS knowledge, 54 females/11 males, and median age of 21 years (IQR = 19–23).	Pretrial: Not mentioned if instructions were given, there was manikin practice. Trial: Two minutes of hands CCs and 2 min of leg-foot CCs and vice versa (n = 65). At least two minutes rest between both techniques.	Favors the hands CCs, as it resulted in higher CPR quality, better compression rate, and more accurate depth compared to the leg-foot CCs.
Ott, et al., 2021,44 (Germany), non-randomised manikin study	20 healthcare professionals (nurses and physicians), with adult BLS knowledge, no gender age of 29.3 ± 6.5 years.	Pretrial: Instructions, no manikin practice mentioned. Trial: Two minutes of hands CCs and 2 min of leg-foot CCs (n = 20). At least five minutes rest between both techniques.	Favors no specific technique, as there were no significant differences between the hands CCs and leg-foot CCs in terms of compression depth, rate, or recoil.
Phusinakkaragul, Jongaramrueng, 2024,45 (Thailand), crossover, randomized controlled manikin study	44 laypersons (schoolchildren), no previous experience in adult BLS training data, 26 females/18 males, aged between 13–15 years	Pretrial: Instructional video and manikin practice. Trial: Two minutes of hands CCs and 2 min of leg-foot CCs and vice versa (n = 44). Ten minutes rest between both techniques.	Favors the hands CCs, as it resulted in a higher compression rate and better chest recoil, while the leg-foot CCs achieved greater compression depth, making it a possible alternative in specific situations.
Lee, et al., 2025,35 (Republic of Korea), crossover, randomised controlled manikin study	72 pre-licensure (university) students, with adult BLS knowledge, 49 females/23 males, age of 22.2 ± 1.9 years.	Pretrial: Instructions and manikin practice. Trial: Two minutes of hands CCs and 2 min of leg-foot CCs and vice versa (n = 72). Thirty minutes rest between both techniques.	Favors the hands CCs, as it resulted in a higher compression accuracy, better recoil, and more consistent compression rate, while the leg-foot CCs achieved comparable depth and could serve as an alternative when hands CCs are not feasible.
Degel et al., 2025,36 (Germany), randomized controlled crossover manikin study	121 pre-licensure (medical) students, with adult BLS knowledge, 78 females/43 males, age 21 to 40 years.	Pretrial: Instructions on technique, but no practice on a manikin mentioned. Trial: Five minutes of hands CCs and 5 min of leg-foot CCs (n = 60) versus vice versa (n = 61). No rest between both techniques.	Favors no specific technique, as the hands CCs and leg-foot CCs showed similar compression depth and effectiveness. However, the leg-foot CCs resulted in more stable compression rates and less fatigue over time.

CCs: chest compressions; USA: United Stated of America.

Effectiveness of the leg-foot CCs compared to hands CCs

Four studies published between 1978 and 198013, 16, 37 followed the 1974 AHA resuscitation guidelines⁴⁶ and Kardiopulmonale Wiederbelebung (German; Cardiopulmonary Resuscitation in English),⁴⁷ which defined high-quality CCs with a 5:1 CCs-to-rescue breath ratio, a depth of 3.8–5.1 cm (or 4–5 cm), a rate of 60–80 CCs per minute, and placement one finger-breadth above the xiphoid process, identified by tracing the lower rib margin. Ten studies published between 2015 and 202535, 36, 38, 39, 40, 41, 42, 43, 44, 45 followed the AHA / ERC 2010,38, 39 2015,40, 41, 42, 43, 44 2020⁴⁵ and 202111, 35 adult BLS guidelines, which define high-quality CCs with a 30:2 CCs-to-rescue breath ratio as CCs, a depth of at least 5 cm but no more than 6 cm, a rate of 100–120 per minute, full chest recoil after each CCs, and delivered CCs on the lower half of the sternum (“centre of the chest”).2, 3, 18, 48, 49 Two studies included leg-foot CCs with rescue breathing,16, 37 while the others examined leg-foot CCs only.13, 15, 35, 36, 38, 45, 40, 41, 42, 43 CCs depth: Twelve studies13, 15, 16, 40, 41, 35, 36, 37, 38, 43, 44, 45 compared CCs depth between leg-foot and hands techniques. These studies involved subgroups based on weight,13, 45, 36, 37, 38 population/participants,³⁷ gender³⁶ and whether a balance aid was used during leg-foot CCs.⁴⁰ Eight studies15, 16, 41, 44, 35, 36, 37, 38 reported no differences in CCs depth across these subgroups. However, among participants with higher body weight,13, 36, 45 only one study¹³ reported differences for the leg-foot CCs technique. Additionally, one study⁴⁰ observed improved performance when a balance aid, such as a footstool, was used during leg-foot CCs. CCs rate: Nine studies15, 41, 35, 36, 37, 38, 43, 44, 45 compared CCs rate between leg-foot and hands techniques. Two studies37, 45 involved subgroups based on weight,⁴⁵ and population/participants (laypeople vs. healthcare professionals)³⁷ and reporters no differences in CCs rate across these subgroups, whereas other studies35, 36, 38, 43 found differences in CC rates in the overall population. CCs recoil: Six studies16, 35, 38, 43, 44, 45 compared CCs recoil between leg-foot and hands techniques. One study⁴⁵ involved subgroups based on weight and reported no differences in CCs rate across these subgroups, whereas other studies35, 38, 43 found differences in CC recoil in the overall population. CCs location: Eight studies13, 15, 16, 35, 38, 43, 44, 45 compared CCs location between leg-foot and hands techniques. One study15, 37 included subgroup based on weight,⁴⁵ and other based on population/participants (certified vs. non-certified individuals).¹⁵ It reported differences in favour of the heavier group, but no significant differences between certified and non-certified participants when using the leg-foot CC technique. Other studies13, 35, 43 found differences in CC location in the overall population (Table 2).

Table 2.

High-quality CCs parameters.

CCs parameters	Study (1st author surname, 1st author, year, country)	Intervention (leg-foot CCs)	Control (hands CCs)	P value
CCs depth (mm)	Bilfield, Regula, 1978,13 (USA)	Lighter weight group (mean all 58.5 kg): Mean 48.45 ± 4.19 mm	Lighter weight group (mean all 58.5 kg): Mean 42.63 ± 3.32 mm	NS
		Heavier weight group (mean all 73.9 kg): Mean 46.54 ± 4.70 mm	Heavy weight group (mean all 73.9 kg): Mean 46.00 ± 3.50 mm	p < 0.05
		Groups together (mean all 66.2 kg): Mean 47.50 ± 4.45 mm	Groups together (mean all 66.2 kg): Mean 44.32 ± 3.41 mm	p < 0.01
	Donegan, 1979,37 (USA)	Lighter weight group (mean all 55.5 kg): Mean 43.5 ± 4.5 mm	Lighter weight group (mean all 55.5 kg): mean 42.5 ± 4.4 mm	NS
		Heavier weight group (mean all 80.9 kg): Mean 48.9 ± 3.7 mm	Heavy weight group (mean all 80.9 kg): mean 44.2 ± 4.2 mm	NS
		CPR certified: Mean 46.1 ± 4.1 mm	CPR certified: Mean 43.2 ± 4.3 mm	NS
		Not CPR certified: Mean 46.0 ± 4.1 mm	Not CPR certified: Mean 43.5 ± 4.2 mm	NS
		Groups together: Mean 46.1 ± 4.1 mm	Groups together: Mean 43.3 ± 4.3 mm	NS
	Sefrin, Albert, 1979,15 (Germany)	First two minutes of a 12-minute period (laypeople): Mean 51.9 ± 8.5 mm	First two minutes of a 12-minute period (laypeople): Mean 54.2 ± 7.9 mm	NA
		Last two minutes of a 12-minute period (laypeople): Mean 52.8 ± 6.0 mm	Last two minutes of a 12-minute period (laypeople): Mean 57.8 ± 7.3 mm	NA
		First two minutes of a 12-minute period (HP): Mean 52.7 ± 11.1 mm	First two minutes of a 12-minute period (HP): Mean 55.2 ± 11.6 mm
		Last two minutes of a 12-minute period (HP): Mean 50.8 ± 11.6 mm	Last two minutes of a 12-minute period (HP): Mean 52.0 ± 11.9 mm
	Jost, 1980,16 (Germany)	0 out of 60 participants not deep enough	2 out of 60 participants not deep enough	NA
	Kherbeche, et al., 2015,38 (Switzerland)	Body weight (≥50 kg) 61 % (mean) correct CCs depth	Body weight (≥50 kg) 56 % (mean) correct CCs depth	p = 0.57
		Body weight (<50 kg) 23 % (mean) correct CCs depth	Body weight (<50 kg) 34 % (mean) correct CCs depth	p = 0.2
		47 % (mean) correct depth per test participant	45 % (mean) correct depth per test participant	p = 0.76
	Takahashi, et al., 2018,40 (Japan)	Leg-foot (LF) CCs: ≤40 mm (median 3 (IQR 1–12) CCs); 40–50 mm (median 140 (IQR 106–163) CCs); ≥50 mm (median 57 (IQR 23–105) CCs)	≤40 mm (median 1 (IQR 0–18) CCs); 40–50 mm (median 149 (IQR 90–190) CCs); ≥50 (median 20 (IQR 1–126) CCs)	LF + FS vs. hands: p < 0.01
		Leg-foot CCs with a footstool (LF + FS): ≤40 mm (median 0 (IQR 0–0) CCs); 40–50 mm (median 15 (IQR 0–47) CCs); ≥50 mm (median 187 (IQR 146–203) CCs)		LF + FS vs. LF: p < 0.01
	Cairol Barquero, et al., 2019,41 (Costa Rica)	Mean 55.5 mm (CI 95 %: 53.7–57.3)	Mean 51.6 mm (CI 95 %: 48.4–54.8)	NA
	Otero-Agra, et al., 2021,43 (Spain)	Mean depth 50 mm (IQR 46–53)	Mean depth 51 mm (IQR 47–55)	p = 0.51
		45 % CCs with correct depth (IQR 23–55)	60 % CCs with correct depth (IQR 28–85)	p = 0.01
	Ott, et al., 2021,44 (Germany)	Mean 46.8 ± 9.3 mm; median 51.0 (IQR = 1.0 − 81.5)	Mean 49.6 ± 8.8 mm; median 45.5 (IQR = 7.0 − 98.3)	NA*
	Phusinakkaragul, Jongaramrueng, 2024,45 (Thailand)	Body weight < 50 kg: Mean 35.67 mm (±6.21; CI 95 %: 33.21–38.12)	Body weight < 50 kg: Mean 23.11 mm (±3.67; CI 95 %: 21.66–24.56)	p < 0.001 (all groups)
		Body weight ≥ 50 kg: Mean 47.00 mm (±7.49; CI 95 %: 43.15–50.85)	Body weight ≥ 50 kg: Mean 28.82 mm (±3.03; CI 95 %: 27.27–30.38)
		Total: Mean 40.05 mm (±8.68; CI 95 %: 37.41 − 42.68)	Total: Mean 25.32 mm (±4.41; CI 95 %: 23.98 − 26.66)
	Lee, et al., 2025,35 (Republic of Korea)	Mean depth 53.3 ± 5.6 mm	Mean depth: 51.5 ± 5.8	p = 0.035
	Degel et al., 2025,36 (Germany)	Mean 49.9 mm (±9.4; CI 95 %: 48.2 − 51.5)	Mean 49.8 mm (±8.7; CI 95 %: 48.2 − 51.4)	p = 0.953
CCs rate (n/min)	Donegan, 1979,37 (USA)	Groups together: mean 59.3 ± 5.1	Groups together: mean 62.5 ± 5.6	NA
	Sefrin, Albert, 1979,15 (Germany)	First two minutes of a 12-minute period (laypeople): Mean 70.2 ± 8.6	First two minutes of a 12-minute period (laypeople): Mean 71.6 ± 8.1	NA
		Last two minutes of a 12-minute period (laypeople): Mean 67.4 ± 7.3	Last two minutes of a 12-minute period (laypeople): Mean 67.3 ± 7.7	NA
		First two minutes of a 12-minute period (HP): Mean 65.4 ± 8.0	First two minutes of a 12-minute period (HP): Mean 65.6 ± 8.0	NA
		Last two minutes of a 12-minute period (HP): Mean 63.8 ± 7.3	Last two minutes of a 12-minute period (HP): Mean 63.8 ± 7.3	NA
	Kherbeche, et al., 2015,38 (Switzerland)	86 % (mean) achieved the required CCs frequency	98 % (mean) achieved the required CCs frequency	p = 0.03
	Otero-Agra, et al., 2021,43 (Spain)	Mean 108/min (IQR 99–116)	Mean 114/min (IQR 107–119)	p < 0.001
		58 % CCs with correct rate	93 % CCs with correct rate	p < 0.001
	Cairol Barquero, et al., 2019,41 (Cost Rica)	Mean 113.38/min (CI 95 %: 108.82–117.94)	Mean 114.98/min (CI 95 %: 110.45–119.47)	NA
	Ott, et al., 2021,44 (Germany)	Mean 112.9/min (±19.7); Median 21,5 (IQR = 4.0 − 95.8)	Mean 122/min (±16.4); Median 11.5 (IQR = 0.8 − 87.0)	NA*
	Phusinakkaragul, Jongaramrueng, 2024,45 (Thailand)	Body weight < 50 kg: Mean 99.63 (±9.18; CI 95 %: 96.12 − 103.14)	Body weight < 50 kg: Mean 109.04 (±11.32; CI 95 %: 105.08 − 112.99)	NA
		Body weight ≥ 50 kg: Mean 95.65 (±9.37; CI 95 %: 90.83 − 100.47)	Body weight ≥ 50 kg: Mean 110.00 (±13.46; CI 95 %: 103.08 − 116.92)	NA
		Total: Mean 98.09 (±9.18; CI 95 %: 95.30 − 100.88)	Total: Mean 109.41 (±11.32; CI 95 %: 105.97 − 112.85)	NA
	Lee, et al., 2025,35 (Republic of Korea)	Mean 107.5 ± 10.5	Mean 112.0 ± 6.2	p = 0.001
	Degel et al., 2025,36 (Germany)	Mean 113 (±16; CI 95 %: 110–116)	Mean 120 (±13; CI 95 %: 118 − 123)	p = 0.01
CCs recoil (%)	Jost, 1980,16 (Germany)	17 out of 60 participants	4 out of 60 participants	NA
	Kherbeche, et al., 2015,38 (Switzerland)	91 % (mean)	99 % (mean)	p = 0.001
	Otero-Agra, et al., 2021,43 (Spain)	Median 76 % (IQR 50–87)	Median 100 % (IQR 87–100)	p < 0.001
	Phusinakkaragul, Jongaramrueng, 2024,45 (Thailand)	Body weight < 50 kg: Mean 79.96 (±20.47; CI 95 %: 71.87–88.06)	Body weight < 50 kg: Mean 99.74 (±1.16; CI 95 %: 99.28 − 100.20)	NA
		Body weight ≥ 50 kg: Mean 62.71 (±24.56; CI 95 %: 50.08–75.33)	Body weight ≥ 50 kg: Mean 99.06 (±3.15; CI 95 %: 97.44 − 100.68)	NA
		Total: Mean 73.30 (±23.45; CI 95 %: 66.17 − 80.43)	Total: Mean 99.48 (±2.15; CI 95 %: 98.82 − 100.13)	NA
	Ott, et al., 2021,44 (Germany)	Median 84.0 (IQR = 28,0 − 97,0)	Median 71.5 (IQR = 17.5 − 99.75)	NA*
	Lee, et al., 2025,35 (Republic of Korea)	Mean 61.0 ± 31.1	Mean 73.4 ± 33.6	p = 0.003
CCs position (%)	Bilfield, Regula, 1978,13 (USA)	Leg-foot CCs gave significantly less misplaced compression than the hands CCs technique.		p = 0.01
		The differences between CPR and non-CPR participants were not significant for percent misplaced compressions.		NA
	Donegan, 1979,37 (USA)	The lighter group had fewer misplaced compressions with the hands CCs than with leg-foot CCs.		NS
		The heavier group had fewer misplaced compressions with the leg-foot CCs		p < 0.05
	Sefrin, Albert, 1979,15 (Germany)	Maintaining the CCs position was more challenging for laypersons than HP (60 % vs. 36 %) when using leg-foot CCs.		NA
	Jost, 1980,16 (Germany)	17 out of 60 participants	4 out of 60 participants	NA
	Kherbeche, et al., 2015,38 (Switzerland)	Maintained for 98 % (mean) of CCs	Maintained for 98 % (mean) of CCs	NA
	Otero-Agra, et al., 2021,43 (Spain)	Median 100 % (IQR = 89 − 100)	Median 100 % (IQR = 100 − 100)	p = 0.002
	Ott, et al., 2021,44 (Germany)	Median 100 % (IQR = 73,3 − 100)	Median 100 % (IQR = 100 − 100)	NA**
	Lee, et al., 2025,35 (Republic of Korea)	Mean 84.3 ± 33.7	Mean 99.5 ± 2.3	p < 0.001

CCs: chest compressions; USA: United Stated of America; CPR: cardiopulmonary resuscitation; CI: Confidence interval; IQR: Interquartile range; mean ± standard deviation; NS: not significant; NA: not available; HP: healthcare professionals; *High-density interval and region of practical equivalence presented “Undecided” result; **High-density interval and region of practical equivalence presented “Equivalent” result.

Feasibility and acceptability of the leg-foot to hands CCs

Across the studies included, most scenarios involved a single rescuer performing leg-foot CCs,13, 35, 36, 38, 39, 40, 41, 42, 43, 44, 45 while three studies examined two-person performance15, 16, 37. Heel placement was the most common foot position,13, 15, 16, 36, 37, 39, 40, 43, 44, 45 with fewer studies using the foot35, 41, 42 or the ball of the foot³⁸. Regarding footwear, many participants performed CCs without footwear13, 15, 16, 35, 44, 45, 37, 38, 39, 40, 41, 42, while a smaller portion wore footwear.36, 43 The rescuer’s body position was primarily parallel to the manikin.13, 15, 16, 40, 35, 36, 37, 38, 43, 44, 45 Few studies incorporated rescuer stabilization support for leg-foot CCs, utilizing external aids such as a chair,³⁶ footstool,⁴⁰ or horizontal bar.⁴² The manikin type varied across studies, with the majority using full-body manikins (Table 3).15, 16, 41, 44, 45, 35, 36, 37

Table 3.

Characteristics of leg-foot CCs.

Study (1st author surname, 1st author, year, country)	Number of persons performing leg-foot CCs	Performing leg-foot CCs with rescue breathing	Foot placement for leg-foot CCs	Footwear used for leg-foot CCs	Rescuer's position for leg-foot CCs	Number of feet used for leg-foot CCs	Stabilization support for leg-foot CCs	CCs audio video feedback
Bilfield, Regula, 1978,13 (USA)	One person	No	Heel	No footwear	Parallel to the manikin's sternum	1	No	No
Donegan, 1979,37 (USA)	Two persons	Yes	Heel	No footwear	Parallel to the manikin's sternum	1	No	No
Sefrin, Albert, 1979,15 (Germany)	Two persons	No	Heel	Barefoot	Parallel to the manikin's sternum	1	No	No
Jost, 1980,16 (Germany)	Two persons	Yes	Heel	No footwear	Parallel to the manikin's sternum	1	No	Yes
Kherbeche, et al., 2015,38 (Switzerland)	One person	No	Ball of foot	No footwear	Parallel to the manikin's sternum	1	No	Audio
Trenkamp, Perez, 2015,39 (USA)	One person	No	Heel	No footwear	Standing beside the manikin’s head, with the supporting leg parallel to the manikin sternum	1	No	Audio
Takahashi, et al., 2018,40 (Japan)	One person	No	Heel	No footwear	Parallel to the manikin's sternum	1	Yes, footstool	Audio
Cairol Barquero, et al., 2019,41 (Costa Rica)	One person	No	Foot	No footwear	Standing beside the manikin’s head, with the supporting leg parallel to the manikin sternum	1	No	No
Lau, Yamamoto, 2021,42 (USA)	One person	No	Foot	No footwear	Perpendicular to the manikin sternum	2	Yes, horizontal bar connected to a step stool	Audio
Otero-Agra, et al., 2021,43 (Spain)	One person	No	Heel	Yes, for both feet	Parallel to the manikin's sternum	1	No	Not specified
Ott, et al., 2021,44 (Germany)	One person	No	Heel	No footwear	Parallel to the manikin's sternum	1	No	No
Phusinakkaragul, Jongaramrueng, 2024,45 (Thailand)	One person	No	Heel	No footwear	Parallel to the manikin's sternum	1	No	No
Lee, et al., 2025,35 (Republic of Korea)	One person	No	Foot	No footwear	Parallel to the manikin's sternum	1	No	No
Degel et al., 2025,36 (Germany)	One person	No	Heel	Yes, footwear for weight-bearing foot and no footwear for working foot	Parallel to the manikin's sternum	1	Yes, chair	No

CCs: chest compressions; USA: United Stated of America; NA: not available.

Anthropometric parameters of participants were measured in seven studies,35, 36, 40, 42, 43, 44, 45 with weight35, 36, 40, 42, 43, 44, 45 and height35, 36, 40, 42, 43, 44, 45 being the most assessed.35, 36, 40, 42, 43, 44 In contrast, body mass index (BMI), sole size, and body surface area were less frequently measured (three studies35, 43, 44 vs. two studies35, 40 vs. one study.⁴⁰ The BMI of participants in the studies fell within the normal range (Table 4).35, 43, 44

Table 4.

Anthropometric parameters of participants.

Anthropometric parameters	Study (1st author surname, 1st author, year, country)	Measurements
Height (cm)	Takahashi, et al., 2018,40 (Japan)	165.6 ± 8.2
	Lau, Yamamoto, 2021,42 (USA)	147.9 ± 14.6
	Otero-Agra, et al., 2021,43 (Spain)	Median 166 (IQR = 162–172)
	Ott, et al., 2021,44 (Germany)	174 ± 1
	Phusinakkaragul, Jongaramrueng, 2024,45 (Thailand)	160.17 ± 6.7
	Degel et al., 2025,36 (Germany)	174.1 (±9.2; IQR = 153–194)
	Lee, et al., 2025,35 (Republic of Korea)	165.9 ± 7.4
Weight (kg)	Takahashi, et al., 2018,40 (Japan)	59.1 ± 11.0
	Lau, Yamamoto, 2021,42 (USA)	42.7 ± 13.8
	Otero-Agra, et al., 2021,43 (Spain)	Median 64 (IQR = 58–78)
	Ott, et al., 2021,44 (Germany)	70.6 ± 15.2
	Phusinakkaragul, Jongaramrueng, 2024,45 (Thailand)	50.89 ± 12.4
	Degel et al., 2025,36 (Germany)	68.3 (±12.1; IQR = 43–102)
	Lee, et al., 2025,35 (Republic of Korea)	64.5 ± 11.7
BMI (kg/m2)	Otero-Agra, et al., 2021,43 (Spain)	Median 23 (IQR = 21 − 25)
	Ott, et al., 2021,44 (Germany)	23.2 ± 3.8
	Lee, et al., 2025,35 (Republic of Korea)	23.3 ± 3.3
Sole size (cm)	Takahashi, et al., 2018,40 (Japan)	25.1 ± 1.6
	Lee, et al., 2025,35 (Republic of Korea)	24.59 ± 1.52
Body surface area (cm2)	Takahashi, et al., 2018,40 (Japan)	1.7 ± 0.2

IQR: Interquartile range; BMI: Body mass index; USA: United Stated of America; Cm: centimetres; Kg: kilogram; mean ± standard deviation.

Regarding the physiological parameters of participants, we observed that heart rate,40, 41 systolic40, 41 and diastolic40, 41 blood pressure, respiratory rate,⁴⁰ and SpO₂⁴⁰ of rescuers were frequently evaluated when performing leg-foot and hands CCs. Systolic and diastolic blood pressure,40, 41 as well as SpO₂,⁴⁰ remained within normal ranges for adults. However, heart rate40, 41 and respiratory rate⁴⁰ were higher than normal, especially after performing hands or leg-foot CCs (Table 5).

Table 5.

Physiological parameters of participants.

Physiological parameters	Study (1st author surname, 1st author, year, country)	Intervention (leg-foot CCs)	Comparison (hands CCs)
Heart rate (BPM)	Takahashi, et al., 2018,40 (Japan)	123 ± 22 With footstool: 107 ± 15	123 ± 21
	Cairol Barquero, et al., 2019,41 (Costa Rica)	Before: 86.70 + 5.56 After: 111.97 + 8.17 (CI 95 %: 103.8–120.14)	Before: 85.55 + 6.23 After: 116.94 + 9.57 (CI 95 %: 107.37–126.51)
Systolic blood pressure (mmHg)	Takahashi, et al., 2018,40 (Japan)	133 ± 11 With footstool: 126 ± 11	133 ± 15
	Cairol Barquero, et al., 2019,41 (Costa Rica)	Before: 106.96 ± 8.71After: 129.99 (CI 95 %: 124.23–135.75)	Before: 106.51 ± 8.5After: 129.99 (CI 95 %: 124.29–135.75)
Diastolic Blood Pressure (mmHg)	Takahashi, et al., 2018,40 (Japan)	77 ± 14 With footstool: 74 ± 12	74 ± 13
	Cairol Barquero, et al., 2019,41 (Costa Rica)	Before: 60.16 (CI 95 %: 54.67–65.65)After: 69.21 (CI 95 %: 65.58–72.84)	Before: 61.09 (CI 95 %: 55.48–67.51)After: 69.21 (CI 95 %: 65.58 – 72.84)
Respiratory rate (breaths per minutes)	Takahashi, et al., 2018,40 (Japan)	24 ± 5 With footstool: 20 ± 5	25 ± 8
SpO2 (%)	Takahashi, et al., 2018,40 (Japan)	98 ± 1 With footstool: 98 ± 1	98 ± 1

BPM: Beat per minute; BMI: Body mass index; CI: Confidence interval; mean ± standard deviation.

Perception of fatigue during CCs was assessed in five studies,15, 36, 40, 41, 43 using measures such as perceived exertion,⁴¹ questionnaire,¹⁵ the modified Borg scale,⁴⁰ visual analogue scale,⁴³ and changes in CCs depth and rate.³⁶ Two studies40, 41 found that the leg-foot CCs resulted in lower perception of the fatigue compared to the hands CCs. One study³⁶ reported mixed results, showing less fatigue reflected in CCs rate but not in CCs depth when using the leg-foot CCs (Table 6).

Table 6.

Perception of the participants fatigue.

Study (1st author surname, 1st author, year, country)	Measurement tools	Results
Sefrin, Albert, 1979,15 (Germany)	Questionnaire	Perception of fatigue was more common in laypersons (40 %) than healthcare professionals (20 %) during leg-foot vs. hands CCs.
Takahashi, et al., 2018,40 (Japan)	Modified Borg scale	The modified Borg scale shows lower perfection of fatigue using leg-foot CCs with footstool in comparison with hands CCs or leg-foot CCs without footstool.
Cairol Barquero, et al., 2019,41 (Costa Rica)	Perception	Among performers, 52.94 % of participants reported that performing hands CCs caused more perception of fatigue than with leg-foot CCs (47.06 %).
Otero-Agra, et al., 2021,43 (Spain)	Visual analogue scale	The perception of fatigue was significantly higher with leg-foot CCs compared to the hands CCs.
Degel et al., 2025,36 (Germany)	CCs depth over time	Among high performers (CC depth ≥ 50 mm), perception of fatigue was more pronounced in the hands CCs.
Degel et al., 2025,36 (Germany)	CCs rate over time	The perception of fatigue was less pronounced in the leg-foot CCs. While the hands CCs initially achieved greater depths, it soon aligned with the leg-foot CCs and ultimately ended lower, though the difference was not statistically significant.

CCs: chest compressions.

Discussion

Our review of 14 manikin-based studies highlights heterogeneity in the performance of leg-foot CCs and identifies a greater number of feasibility parameters compared to hands CCs. Leg-foot CCs may meet the parameters of high-quality chest compressions. However, most studies found no significant subgroup differences, though some noted better performance with heavier participants or balance aids, and differences in compression rate, recoil, or hand placement. Many of the studies included were conducted in Europe and North America, with only a few conducted in culturally diverse countries where leg-foot CCs may not be well accepted due to religious or cultural beliefs.

Effectiveness of the leg-foot CCs compared to hands CCs

Leg-foot CCs depth was assessed in many studies.13, 15, 16, 40, 41, 35, 36, 37, 38, 43, 44, 45 Only a few met the 1974 AHA resuscitation guidelines1, 2 or the 2010–2021 AHA/ERC adult BLS guidelines.1, 2, 3 CCs rate was also evaluated in several studies,15, 41, 35, 36, 37, 38, 43, 44, 45 with just a small number meeting the respective guideline targets.15, 35, 36, 41, 43, 44 CCs recoil was examined in about half of the included studies,16, 35, 38, 43, 44, 45 with few showing correct recoil.38, 43, 44 CCs location was measured in most studies,13, 15, 16, 35, 38, 43, 44, 45 though only a few demonstrated correct positioning.38, 43, 44 Overall, while leg-foot CCs can occasionally meet quality benchmarks, their consistency and reliability remain limited. Recently published trials30, 31, 38, 39 provide more robust insights into the effectiveness and fatigue-related outcomes of leg-foot CCs, especially when compared with the earlier none-randomized studies. Among these, recent studies by Lee et al.,³⁵ and Degel et al.³⁶ stand out in terms of methodological rigor and sample size, and therefore advance our understanding the most. These studies35, 36 help clarify the potential of leg-foot CCs in situations involving fatigue, physical limitations, or extended duration resuscitation scenarios. Future research could build on these more rigorous designs to further investigate acceptability and real-world application, particularly in subgroups (e.g., young schoolchildren) who lack the force to provide high-quality hands CCs. In a 2015 study,³⁸ leg-foot CCs showed slightly better depth, especially in heavier schoolchildren, but hands CCs led to significantly more correct rates. The 2024 study⁴⁵ confirmed this trend in schoolchildren—leg-foot CCs produced greater depth, particularly in rescuers ≥ 50 kg, while hands CCs ensured better rate and recoil. Through both studies,45, 50 weight influenced performance, but hands CCs remained more reliable overall for meeting guideline targets. Additionally, a recent 2025 study³⁶ showed that lower body weight in adult rescuers was associated with reduced CCs depth when using hands but had no effect on CCs depth during leg-foot CCs. One of the limitation of those studies36, 38, 45 is their small, combined sample size of less than 300 participants, which limits the generalizability of their findings. In contrast, the large-scale ongoing study,³⁴ presented at the Resuscitation Science Symposium and involving over 700 schoolchildren, may have a greater impact on future guidelines—potentially favoring either leg-foot or hands CCs for this population.

Feasibility and acceptability of the leg-foot CCs

Regarding the feasibility and acceptability of leg-foot CCs, studies have examined parameters such as rescuer position, foot placement, footwear, and body support. In contrast, hands CCs follow a standardized approach: kneeling beside the person, placing hands on the lower sternum, and keeping arms straight. Unlike the standardized hand compression technique, leg-foot methods vary. Most studies used the heel for CCs,13, 15, 16, 36, 37, 39, 40, 43, 44, 45 while fewer tested the entire foot35, 41, 42 or ball of the foot.³⁸ The most common rescuer position for leg-foot CCs was parallel to the sternum, likely with the left foot bearing weight and the right leg performing CCs. This raises the question of whether the dominant leg is better used for balance or for delivering CCs.⁴¹ Most participants performed leg-foot CCs barefoot, with only one study using footwear to better simulate real-life scenarios.⁴³ However, barefoot CCs may provide better haptic feedback,³⁶ similar to performing hands CCs with winter gloves.⁵¹ However, most out-of-hospital cardiac arrests occur at home,52, 53 where people are usually barefoot or wearing socks or slippers.⁵⁴ Additionally, authors claim that wearing footwear provides greater stability,16, 33, 40, 44, 55 as floors can be slippery and pose a hazard. As a result, in the study by Degel et al., participants wore a shoe on the weight-bearing foot while keeping the “working foot” without footwear.³⁶ Additionally, only few studies included balance object, like stool or chair, for stabilize the upper body of the participants when performing leg-foot CCs36, 42 and to prevent potential falls.⁵⁵ One study reported that participants experienced balance difficulties while performing leg-foot CCs.⁵⁶ Authors claim that balance objects, like walls or pillars, are rarely included because they are typically unavailable in emergency situations,⁴ where other claim it could help with performing CCs.40, 42 However, the question remains whether performing leg-foot CCs with or without footwear reduces the risk of skin/bone injuries to the person and ensures a more hygienic procedure by minimizing the transfer of dirt from the foot or footwear to the person's skin. One study assessed participants' perceived injury risk to the patient from, reporting a higher perceived risk than for hands CCs. Additionally, while participants preferred hands CCs,15, 37, 43 leg-foot CCs were the second choice in most participants.⁴³

In our review, many of the studies included rest phases between hands and leg-foot CCs.13, 35, 37, 39, 40, 42, 43, 44, 45 This raises the question of whether rescuers could seamlessly continue resuscitation with leg-foot CCs after hands CCs. A recent study demonstrated that leg-foot CCs reduced fatigue in those achieving target depth.³⁶ Authors concluded that, since rescuer fatigue is a major challenge during prolonged resuscitation, alternating between leg-foot CCs and hands CCs could be an effective strategy for single35, 36 or pair rescuers.15, 37 Our review confirmed that leg-foot CCs may help reduce fatigue compared to the hands CCs, potentially making it a more sustainable option for prolonged resuscitation efforts.15, 37 Interestingly, two studies investigated the use of leg-foot CCs with rescue breaths, applying a 5:1 CCs-to-rescue breath ratio.16, 37 Future research could explore the 30:2 CCs-to-rescue breath in both two-rescuer and lone-rescuer scenarios to assess whether it leads to prolonged hands-off time and reduce rescue fatigue.

Leg-foot CCs in diverse cultural contexts

Most of the included studies were conducted in the Western world countries,13, 15, 16, 36, 37, 38, 39, 42, 43, 44 with only a few in culturally diverse countries where leg-foot CCs may not be well accepted due to religious or cultural beliefs.35, 40, 45 Cultural norms and religious traditions in Eastern and Arab societies play a significant role in shaping perceptions of medical practices.57, 58 For example, in Middle Eastern cultures, feet are often considered unclean or disrespectful,⁵⁹ which may lead to resistance toward their use in life-saving techniques. Additionally, traditional values in the country emphasize respect for the body, making unconventional techniques like leg-foot CCs seem inappropriate. While Europe and the North America have well-established resuscitation training programs that prioritize innovation,60, 61 adult BLS training remains less widespread in many parts of Asia, particularly in rural areas, making the introduction of novel techniques more challenging.⁶² In many Asian countries, the feet are often considered impure,⁶³ and placing one’s foot on another person, especially on the chest, may be viewed as highly offensive. Our review included three studies from culturally diverse countries—Thailand,⁴⁵ Japan,⁴⁰ and the Republic of Korea³⁵—none of which reported issues when performing leg-foot CCs on manikins. However, applying this technique in real-world settings may be challenged by cultural or religious norms, particularly where feet are considered disrespectful or modesty rules restrict cross-gender contact in public.⁶⁴ In such regions, implementation would require culturally sensitive approaches, ethical consideration, and community engagement.

Limitations

Our review has some limitations. First, although we included all studies with an English abstract, we only analyzed full texts written in English, German, and Spanish. While modern translation tools reduce language barriers, the reliance on English abstracts may have excluded potentially relevant studies published in other languages. Broader linguistic inclusion could enhance the comprehensiveness and global representativeness of future reviews.⁶⁵ Second, as this was a scoping review, we did not conduct a formal data synthesis (e.g., meta-analysis), nor did we assess the risk of bias or the certainty of evidence in the included studies. To support evidence-based recommendations and inform policy decisions on leg-foot CCs practices, future systematic reviews with rigorous data synthesis and formal appraisal of study quality and evidence certainty are needed. Additionally, future reviews should account for study results based on outdated guidelines.

Conclusion

No human studies of leg-foot CCs were identified. When performed on manikins, this scoping review found that leg-foot CCs are feasible, acceptable and variably effective, but results were inconsistent. All identified studies were simulation-based, limiting real-world relevance. Further research, especially in human populations, is needed to evaluate effectiveness, fatigue, and acceptability—particularly for those unable to perform standard hands CCs.

CRediT authorship contribution statement

Nino Fijačko: Writing – review & editing, Writing – original draft, Visualization, Supervision, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Kristina McShea: Writing – review & editing, Formal analysis, Data curation, Conceptualization. Eva Dolenc Šparovec: Writing – review & editing, Writing – original draft, Formal analysis. Špela Metličar: Writing – review & editing, Writing – original draft, Visualization, Investigation, Formal analysis, Data curation. Tomaž Horvat: Writing – review & editing, Writing – original draft, Investigation, Data curation. Vinay M. Nadkarni: Writing – review & editing, Writing – original draft, Investigation. Robert Greif: Writing – review & editing, Writing – original draft, Investigation.

Funding

NF is supported by a Fulbright Program grant sponsored by the Bureau of Educational and Cultural Affairs of the U.S. Department of State and administered by the Institute of International Education.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: NF is a member of the ERC BLS Science and Education Committee. VN is a member of the board of directors of ILCOR; and member of the editorial board of Resuscitation. RG is ERC Director of Guidelines, and ILCOR Task Force chair for Education Implementation and Team; and member of the editorial board of Resuscitation Plus. Other authors declare that they have no conflict of interest.

Appendix A. Supplementary material

The following are the Supplementary data to this article: