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A qualitative study of the experiences of patients with knee osteoarthritis undergoing moxibustion
  1. Haeng-Mi Son1,
  2. Duck Hee Kim2,
  3. Eunjeong Kim3,
  4. So-Young Jung4,
  5. Ae-Ran Kim4,
  6. Tae-Hun Kim4,5
  1. 1Department of Nursing, University of Ulsan, Ulsan, Republic of Korea
  2. 2Department of Nursing, Woosuk University, Wanju-gun, Jeonbuk, Republic of Korea
  3. 3Department of Nursing, Gyeongju University, Gyeongju, Republic of Korea
  4. 4Department of Medical Research, Korea Institute of Oriental Medicine, Dae-Jeon, Republic of Korea
  5. 5Department of Spine Center, Mokhuri Neck & Back Hospital, Seoul, Republic of Korea
  1. Correspondence to: Dr Tae-Hun Kim, Mokhuri Neck and Back Hospital, Department of Spine Center, Seoul, Republic of Korea; Department of Medical Research, Korea Institute of Oriental Medicine, 461-24, Jeonmindong, Yuseonggu, Dae-Jeon 305-811, Republic of Korea; rockandmineral{at}gmail.com

Abstract

Objective To explore and understand how patients with knee osteoarthritis (OA) experience moxibustion.

Method This qualitative research was conducted as part of a larger clinical trial of the effectiveness of moxibustion for the treatment of knee OA by qualitative content analysis. Sixteen patients with mild knee OA who participated in a 12-week moxibustion treatment as part of the trial were interviewed using open-ended questions.

Results The participants recognised knee OA as a normal ageing process that caused physical and emotional discomfort in daily life. Regardless of any adverse effects of moxibustion, most of the participants were interested in continuous moxibustion treatment as a long-term management strategy and for general health.

Conclusions This study suggests that moxibustion can be helpful in managing symptoms related to knee OA. Patients’ attitudes towards moxibustion can affect the treatment result and those who prefer it want to continue the treatment for a long time because they understand that knee OA is a chronic condition which needs continuous care. However, practitioners need to pay more attention to those who are very enthusiastic because they tend to endure treatment-related adverse events in their desire for better effects.

  • Acupuncture
  • Rheumatology
  • Osteoporosis Arthritis
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Introduction

Knee osteoarthritis (OA) is a chronic degenerative disease whose major clinical features are pain, swelling, crepitus and bone tenderness at the knee joint. It is caused by damage to the synovial cartilage of the knee.1 With increased average life expectancy and widespread obesity worldwide, the prevalence of knee OA has doubled to tripled over the past few decades.2 In view of the substantial economic burden of knee OA,3 ,4 clinical evidence for the efficacy of various treatments must be evaluated.

Traditional Korean medicine (TKM) includes several techniques for stimulating acupuncture points. One such is moxibustion, which is conducted by burning dried mugwort (Artemisia vulgaris) and applying it directly or indirectly to the skin. Moxibustion has been used to treat various rheumatic conditions including knee OA; rheumatoid arthritis; neck, shoulder and back pain; scar pain and fibromyalgia.5 According to surveys conducted in Korea, acupuncture and moxibustion are two of the most common treatments for knee OA,6 and over half of all TKM practitioners use moxibustion for its treatment.7 Experimental studies suggested that moxibustion might improve knee OA by modulating joint inflammation,8 and act as an analgesic by regulating NO production.9 Many randomised controlled trials have been conducted to evaluate the effectiveness of moxibustion,10 and consensus on its efficacy for musculoskeletal diseases has been established among TKM practitioners.11 ,12 However, this quantitative evidence focused on the symptoms and disability related to knee OA, and did not include the patient's experience and beliefs about the disease and treatment process.

The aim of this study was to describe the experiences of patients with knee OA undergoing moxibustion. We used a mixed-methods approach to study the effectiveness of moxibustion, and interviewed the patients who received moxibustion treatment during the clinical trial to understand its effects and to gather basic information about the patients’ perception of knee OA and moxibustion.

Methods

Sampling and data collection

The participants included 16 patients with knee OA who had participated in a clinical trial for moxibustion (CRIS registry: KCT0000130) and interviewees were selected by convenience sampling. Moxibustion was performed for 15 min per treatment, three times a week for 12 weeks. The application was repeated three times for each treatment. Individual in-depth interviews were conducted after the clinical trial (August 2011 to February 2012) using open-ended questions. The interview questions were devised after discussions between interviewers (H-MS, DHK) and the TKM doctor (T-HK) who designed the clinical trial (see online supplementary appendix 1).

The interviews were recorded and transcribed verbatim. Each interview took about 1½ h, continuing until the participant had no more to say.

The 16 participants included five male and eleven female patients aged 40–49 years (n=4), 50–59 years (n=8) and 60–69 years (n=4). They included three university graduates, nine high-school graduates, three middle-school graduates and one elementary-school graduate. All participants were married.

Duration of the disease varied from >10 years (n=1) to 5–10 years (n=2) to <5 years (n=13). The status of the knee was determined from x-ray images: nine participants were grade 0, three were grade 1, three were grade 2 and one was grade 3, indicating that most participants had minor symptoms (see online supplementary appendix 2).

Data analysis

Qualitative content analysis was used to analyse the text-based data. The goal of the content analysis was ‘to provide knowledge and understanding of the phenomenon under study’.13 The transcribed data in Korean were read line-by-line for coding. The codes were identified from the data and sorted into subcategories and categories based on how different codes are related and linked.13 All categories and statements were translated into English.

Ethical considerations

The Oriental Hospital of Daejeon University's human research ethics committee in Korea approved this study (IRB approval number: DJOMC-74). The participants were fully informed of the purpose and methods of the study before the interview. The researchers adhered to the rules protecting participants, including obtaining informed consent, self-determination, anonymity and confidentiality of information. The participants were compensated for participating in this study.

Study rigour

To guarantee the study rigour, the researchers considered credibility (ie, internal validity of this study), fittingness (ie, external validity), auditability (ie, reliability) and confirmability (ie, objectivity) when conducting this study.14 The research team included three experts (H-MS, DHK and EK), who participated in the interview, data coding and analysis. H-MS and DHK are professors of nursing colleges and participate in qualitative research on patients. EK graduated from a nursing college and was continuing her doctoral course on qualitative research at the time of this study. The participants’ experiences of moxibustion were recorded in individual in-depth interviews. The research team analysed the data by qualitative content analysis. Using the coding scheme, they extracted themes from the data. Then, three researchers debated the categories and concepts of participants’ experiences with moxibustion until they reached a consensus. The data were translated into English by a bilingual translator who was instructed not to alter the content. Additionally, the other three researchers confirmed the translation through internal discussions.

Results

The patients with knee OA had physical and emotional discomfort due to overuse of the knee. Pain, oedema and deformation of the knee joint were not severe in the early stage; however, the symptoms became severe after repeated aggravation and remission, and were accompanied by emotional disturbances, such as depression and lack of confidence. Moxibustion was selected by the participants as a remedy for degenerative OA. While the participants were receiving moxibustion, they reflected on the principles and methods of administration, evaluated its effects, made efforts to maximise the effects and evaluated its efficacy. Through moxibustion and the associated discussion, the patients realised the need to adjust their daily activities to better manage their degenerative OA. The conceptual framework of the experience of patients with degenerative OA undergoing moxibustion follows.

Overuse symptoms

Physical disturbances: knee pains

Most participants had pain and discomfort in the knee. This was caused by activities that place a burden on the knees, such as climbing, heavy exercise and sitting for a long time with the knees bent. Male participants had pain as the result of climbing and over-exercise, while female participants had pain from squatting while doing housework. I have climbed mountains excessively since 4 to 5 years ago. I have climbed 25 km or sometimes 40 km each day. Starting last October, I began to feel discomforting in my right knee. (Participant C, M/47) As I get older, I feel my knees getting worsen. Overall, it was not because of exercise but because of age. (Participant F, F/56)

The participants experienced throbbing and grinding sensations in their knees. They could not bend them, had difficulties while sitting for a long time, dragged their legs when walking and could not run. They had more pain walking downhill than walking uphill and had worse symptoms in bad weather. They observed, assessed and monitored their own symptoms. I had less pain when I climbed stairs or mountains; but when I descended, my knees got the load of weight from my body. I felt more pains and aches. (Participant E, F/57)

The pain fluctuated continuously and most participants took medication when they had symptoms. They did not feel uncomfortable in daily activities, although they were not socially comfortable with the need to straighten their legs when sitting. Thus, most participants did not spend all their time visiting hospitals or clinics to seek treatment. I don't think it causes discomfort every day. I could live on. I do the house chores such as peeling garlic with my legs stretched … I do it in front of my husband. If I must stretch my legs, I do it even though I am with my in-laws in formal setting. We need a place to sit on the chair. I cannot sit on the floor without stretching my legs. I know stretching legs does not look good. But I cannot help it. (Participant H, F/64)

The patients were aware that OA generally becomes more severe over time. I have sharp pains just like cutting with a razor. Too painful that leads to a heavy headache. (Participant A, F/49)

Emotional disturbances

Participants with more severe symptoms had emotional disturbances, including sleeping disturbance and depression; their facial expressions were stiff and sombre, and they thought about death. They were depressed and had lost confidence because they could no longer participate in the activities that they used to enjoy. The participants became self-conscious about the possibility of disturbing others and worried about that. Some participants felt that it was difficult to adjust to their disease. I smiled for a picture; but, when I saw my picture that supposed to be smiling, I noticed that I looked like crying, not smiling. (Participant A, F/49)

Seeking treatment

Some participants sought treatment for OA by visiting hospitals and clinics (for both conventional medicine and TKM). Most of the patients who sought treatment received injections in their knee joint or took drugs and had physiotherapy. One of the participants had a stomach disturbance as a side effect of medicine prescribed by an orthopaedist. One had acupuncture treatment in a TKM clinic but experienced no relief. Another participant did not choose a treatment but consulted friends and neighbours about various treatments and hospitals. I felt discomfort in my knees and went to a hospital. They told me I had degenerative arthritis and gave me medication for 15 days. In taking medication, I had problems with my stomach. Perhaps, the medication was bad for my stomach. Somehow, I was not able to digest my meals. So I stopped, and I did not go back to the hospital again. (Participant B, M/68)

Moxibustion treatment

Deliberating moxibustion methods

The participants had either no knowledge or very basic knowledge about moxibustion. They thought it was a type of thermal treatment and expected improvement in circulation, feelings of warmth and mitigation of the inflammation. I think it is a kind of heating pad because it is hot. Maybe it kills inflammation inside. If I may make a definition of my own... (Participant J, F/52)

The participants used their experience of reduction of symptoms in commenting on the times and duration of moxibustion treatment. Most felt that the 15 min allotted for each moxibustion treatment was appropriate, while the total period of moxibustion treatment given was insufficient to yield the full benefit. The participants felt that the times and period should be lengthened to give them continuous relief. I felt good when I had a therapy. I felt a lot better. But as time goes by, the effects become mitigated. I think if I receive long-term therapy, I may get better. (Participant K, F/54)

Evaluating the moxibustion effects

The effects of moxibustion were evaluated in terms of symptom relief and feelings about moxibustion. The patients felt more comfortable in their everyday lives, as their OA was alleviated by moxibustion. They described their knees as ‘more comfortable’ and ‘relieved of pain’; they also reported that they ‘can bend (their) legs’, that their ‘legs became lighter’ and that they could use fewer analgesics during activities because their knee pain was reduced. Squatting was very uncomfortable for me. So I could not use the traditional-style toilet. The pain and stiffness were in one knee, but it became much more comfortable after moxibustion. Yesterday, I tried the traditional toilet, and I could stand up there without pain on my leg. Amazing! (Participant B, M68)

The responses of the participants differed throughout the treatment. Some experienced relief at the start, and some improved after treatment. Some responded sensitively to moxibustion at the start but became less responsive and lost confidence as the treatment continued. I felt I was getting better from 15 to 20 days after the treatment. But after a month and thereafter, I mean after a long period, I could not feel the effects as before. (Participant K, F/54)

Additionally, the effects of moxibustion were evaluated by the participants’ descriptions of the sensations at the moxibustion sites. Most participants experienced cool, warm or pleasant feelings. They liked the aroma of the moxibustion and suggested that those good feelings were probably the result of improved circulation causing feelings of warmth inside the knees. The participants explained this phenomenon as the result of a ‘good match with moxibustion’. Such a good feelings strengthened their expectations of positive effects. The warm feelings seemed to penetrate into my skin. How can I say? Smearing to the skin? I felt it come to me smoothly. My knees felt very comfortable. (Participant D, F/56) As (the moxibustion treatments) continued, I came to like the smell, I mean the scent. To me, it was OK. It seemed that I had some bad smell, just as though I smoked. I love the aroma of moxibustion. (Participant L, F/61)

Desiring continuation of the moxibustion treatment

Most of the participants evaluated the effects of moxibustion positively and wanted to continue moxibustion treatment with a qualified doctor. They were wary of receiving moxibustion treatment from an unqualified person. On the other hand, some patients considered self-treatment with moxibustion and wanted to be trained in the methods of moxibustion to treat themselves by purchasing the materials. I would like to buy materials and perform moxibustion at this location marked here. I wish I could perform self-treatment at home. (Participant B, M/68)

Maximising the effects of moxibustion

Preferring moxibustion treatment

Those who had positive attitudes toward TKM or who had positive results from such treatments liked moxibustion. Some participants were already aware of the effects of moxibustion as family members had had good results from it and used home remedies. I have been interested in traditional Korean medicine and have faith in it. I have a strong feeling that I will get better by using it. (Participant F, F/56)

Participating actively

Most of the participants participated actively in their treatment and did not miss a session, realising that they could not expect good results if they did not receive the whole treatment. This willing participation was an outcome of their expectations of benefits from moxibustion and positive perceptions of TKM. I was not a good student at school, but I was very good in these sessions. I arrived for sessions on time. (Participant I, F/58)

Enduring side effects of moxibustion

Participants endured side effects to obtain the benefits of moxibustion. Burns are a common adverse effect of moxibustion, as the participants had been informed. Although the severity of burns differed from participant to participant, all had a similar level of anxiety and were concerned about the scarring caused by moxibustion. Burn wounds were more worrying in summer, when fewer clothes are worn. The patients were also worried about exposing burned skin in swimming pools or public baths. At first, it was OK because I could wear long pants in April and May. But now, as it is becoming hot, and I wear shorts, so (the moxibustion site) may be exposed to others. As the shorts cannot cover down here, I am little bit concerned. (Participant A, F/49)

Some participants thought they should endure minor side effects to enjoy the benefits of treatment, even when the treatment resulted in burns. Other participants took it for granted that they would be burned. Another participant responded that she endured the heat because she wanted to maintain her dignity; however, some participants believed that burns could be avoided with due care. Although the doctors told me to inform them if it becomes too hot, I didn't; but kept enduring the heat, as I thought hotter moxibustion would be more effective and would cure my pains better. (Participant D, F/56)

Realising the usefulness of moxibustion

Recommending moxibustion to neighbours

Participants experienced relief of symptoms after moxibustion and recommended it to others. Some who had not benefited from moxibustion still felt that they could recommend it to others because they might be better suited to the treatment. The participants said they would recommend moxibustion because it would be worth trying if it could alleviate the symptoms even a little. These responses reflected individual differences and common evaluations of the effects of moxibustion. If my neighbours ask me about this, I would not say it is not good. I would recommend it as I got better with it. (Participant M, F/69)

Importance of managing health in everyday life

While receiving moxibustion treatment, the interviewees discussed other symptoms related to their knee OA with their practitioners, establishing a close rapport and obtaining a greater understanding of general medical problems. I asked various questions to my doctors and they gave me a kind and insightful explanation on the issues…Generally, if you go to a clinic, you may have only a few minutes to talk with the doctor which makes you frustrated for not getting enough response from your doctor. I could not feel sincerity from their attitudes when my condition was really bad. However, after participating in this treatment, I felt very good because I could ask anything in my mind…from symptoms related to knee OA to other issues (medical problems) I've concerned…(Participant A, F/49)

Through this doctor–patient interaction, they realised that knee OA is a degenerative disease and understood the need to accept its symptoms and related disability. Most of the participants took precautions against the recurrence and aggravation of knee OA symptoms. Most importantly, they recognised that they should not use their knees too much. In my opinion, well, arthritis cannot be cured 100% perfectly. So well, for the purpose of living less painfully during my lifetime…(Participant I, F/58) No. As I consider my age… people said that working out needs to be appropriate to my age…I spare myself…well…not to make pain worse. If possible, I think that it would be better to walk with good posture when I get old. I do not work out too much to avoid bad posture due to bodily pain. (Participant G, F/59)

Meanwhile, the participants perceived the importance of overall health management in everyday life and paid more attention to health information than they had previously. They made various healthy lifestyle choices and were sensitive to health information as they sought the most appropriate approaches. They took supplements and participated in diet programmes and physiotherapy. Most participants exercised extensively. Exercises to build flexibility and muscle power, such as swimming, stretching, yoga and walking, were especially popular. Exercise is a good health-management strategy for patients who must watch their weight. First of all, I think a lot about losing weight. For this, I need to put my thoughts into action. The problem is to carry on my plan. Now I need to eat less…well if I do both of those (losing weight as well as taking treatment for knee OA), it would be helpful (in alleviating my symptoms)…(Participant J, F/52) I tried not to climb mountains, but to walk on a flat land 5 times a week and one hour a day. Every morning! (Participant I, F/58)

Discussion

In this study, the experiences and perceptions of moxibustion treatment were assessed by patients with knee OA. Through this qualitative study, we can understand patients’ experiences of moxibustion and their attitudes towards knee OA and moxibustion itself in Korean culture. Moxibustion is a frequently used intervention for musculoskeletal diseases in TKM clinics,15 but few studies have focused on perceptions of moxibustion and the patients’ reasons for choosing it. For many participants, knee OA was a serious obstacle that caused physical and emotional discomfort in everyday life, with a wide range of severity. The data obtained can provide practitioners with insights that may help them achieve better results from moxibustion treatment.

In this study, we found that most participants held beliefs about the cause and treatment of knee OA. Korean culture traditionally involves sitting on the floor (rather than in a chair) in cross-legged or kneeling postures, which seems to be a problem for patients with knee OA. The participants thought that sitting with straight legs looks impolite but relieves the pain in the affected knee. This experience is specific to patients with knee OA in Asian countries (including Korea) rather than patients in Western countries. As such sitting postures may be a risk factor for knee OA,16 patient education to modify this is necessary to prevent aggravation of symptoms related to knee OA in Korea.

Most patients in this study had tried multiple treatments for managing their symptoms. This practice, commonly called ‘doctor-shopping’, may be related to the chronic progression of knee OA.17 In addition, the patients who decided to participate in this study previously held positive conceptions of TKM and moxibustion treatment. While we are interested in a patient's motivation for selecting moxibustion as a supplementary or principal treatment for knee OA, the patient's preference must also be considered as an important factor that affects treatment results (as with acupuncture and other alternative treatments18). Patients appraised their condition and treatment results at every visit and participated actively in the treatment courses, following their own strategies for good results. Healthcare providers need to consider these consumers’ attitudes when they suggest moxibustion for patients with chronic knee OA.

Many participants wanted to continue moxibustion after the end of treatment and have long-term strategies for managing their symptoms, including administering moxibustion themselves. They wanted opportunities to learn the detailed methods of moxibustion treatment from clinicians. Moxibustion is an invasive treatment that must be practised by qualified TKM doctors, so despite this request patients should not learn to treat themselves.

Many participants thought that the prevalence of knee OA increases with age, and its symptoms are perceived as a discomfort related to the normal ageing process. The lives and daily activities of patients with knee OA are often severely limited, which leads them to seek help in controlling their symptoms.19 Additionally, they wanted to improve their general health as well as alleviating their knee OA symptoms.

Finally, Korean patients tend to regard adverse events related to moxibustion (ie, burns) as a price worth paying to relieve their symptoms; a belief, common to practitioners and patients is that moxibustion-related burns facilitate better outcomes. However, there is no evidence to support this belief and practitioners must take care to protect patients from avoidable injury during moxibustion treatment.

This study has several limitations. First, the results cannot be applied to the general population because the interviewees were limited to participants in a clinical trial. Future studies should recruit a broader sample of patients with knee OA through systematic sampling. Second, there were severe difficulties in translating the participants’ interviews and concepts of the research results from Korean to English. Translation was carried out by a professional translator, who did not participate in this study. Researchers discussed the accuracy of the translated manuscript several times and made changes to ensure that the main concepts were not altered through translation. Even with these efforts, the translations inevitably omit or distort some material. This research is, however, the first qualitative study of moxibustion treatment written in English. We expect that future studies will overcome these problems.

Summary points

  • 16 of 32 patients from a trial of moxibustion for knee OA participated in this qualitative study.

  • Qualitative content analysis was used to analyse the text-based data.

  • Most participants were interested in long-term use of moxibustion.

  • The more enthusiastic patients tend to endure more treatment-related adverse events.

Acknowledgments

All of the authors acknowledge S-MC, who supported this study.

References

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  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

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Footnotes

  • Contributors H-MS designed this study. H-MS, DHK, EK participated in the patients’ interviews and data analysis. H-MS and T-HK wrote the first draft of this manuscript. T-HK, S-YJ and A-RK participated in critical revision of the draft.

  • Funding This study was supported by the project ‘Development of Acupuncture, Moxibustion and Meridian Standard Health Technology’ at the Korea Institute of Oriental Medicine (K12010)

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval The Oriental Hospital of Daejeon University's human research ethics committee in Korea approved this study (IRB approval number: DJOMC-74).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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