Fibromyalgia (FM) is a chronic disorder characterized by widespread musculoskeletal pain and fatigue. It is a less frequently diagnosed disease in China, thus Chinese rheumatologists may have lower awareness of FM compared with colleagues in Western countries. The aim of this study is to investigate the perceptions of FM in Chinese rheumatologists and analyze their therapeutic approach in clinical practice.
An anonymous questionnaire survey was conducted among a nationwide sample of Chinese rheumatologists at the 15th National Rheumatology Conference in 2010. The 20-question survey included questions regarding background, work experience, perceptions of diagnosis and behaviors of treatment related to FM. Continuing medical education (CME) information was also collected in the survey.
Seven hundred and seven rheumatologists responded to the questionnaire, a response rate of 60%. Less than one-fifth of the respondents were experienced in dealing with FM. Although most of the respondents regarded FM as a distinct pathological entity, nearly 30% of Chinese rheumatologists believed that FM was only a psychological disorder. The respondents recognized some of the FM-related symptoms, but had limited knowledge on the diagnostic criteria. Eighty percent of the respondents declared they had difficulties in treating FM patients. However, nearly all (90.8%) respondents believed that the prognosis of FM patients was usually benign. Our data also showed that most Chinese rheumatologists were eager for CME on FM.
The awareness and perception of FM are still low among Chinese rheumatologists. CME on FM is needed for improving the quality of health care in China.
Fibromyalgia (FM) is a distressing disorder characterized by both physiological and psychological symptoms. Its manifestations vary from emotional distress to generalized musculoskeletal pain and systemic characteristics, such as irritable bowel symptoms.[1-3] FM patients frequently suffer from high levels of disability.[4-6] FM is also recognized as one of the most common chronic widespread pain syndromes. Its prevalence has been reported at 0.5–5.0% in various countries.[7-11]
It has been suggested that the prevalence of FM is lower in Chinese compared to other populations, although there is currently no accurate data available.[12-14] In a cross-sectional survey conducted on 14 642 residents in Mentougou town in Beijing, China in 2008 by our group, only four residents were diagnosed as having FM according to the London Fibromyalgia Epidemiology Study Screening Questionnaire.
As a chronic pain syndrome, FM represents 7.5–20.0% of patients in clinics in Western countries. Since primary health care has not been well established in China, Chinese FM patients mainly go directly to rheumatology clinics seeking help. However, it still only accounts for 1.5% of total patients in Chinese rheumatology clinics. Some authors suggest this variation might be due to a differing cultural environment and ethnic differences.[14-18] However, the definitive reasons for low prevalence are not known.
It is implied that there is a wide diversity of perception on FM diagnosis and treatment. In China, FM seems to be ignored from both clinical and research perspectives. There have been very few studies on FM, and these mainly on the role of traditional Chinese medicine and complementary therapy since the 1980s. The silence in related research areas and the low reported incidence of FM in China indicate a potential low awareness of FM by Chinese rheumatologists.
Using a cross-sectional design, we assessed the perception of FM in a cohort of Chinese rheumatologists. The primary objective of the present study was to assess the knowledge, attitude and practice regarding FM by Chinese rheumatologists. Second, there is no data about medical education on FM in China. This study also aimed to obtain information that would be important in planning education programs for Chinese rheumatologists.
This study collected data from a questionnaire-based survey. A 20-item Chinese questionnaire was developed based on previous literature, and then modified according to the opinions of five rheumatologists and two epidemiologists (Appendix S1). Besides background characteristics such as age, sex, professional title and related education experience, the questions covered information about the respondents' perceptions of FM, their clinical experience, the knowledge of diagnostic criteria, their behavior in practice and their attitudes to prognoses. Personal identifying information (e.g., name, birth date and so on) was not collected. The whole assessment took 10–20 min to complete.
Participants and procedure
The survey was conducted during the 15th Annual Congress of Chinese Rheumatology Association (CRA) in 2010. The congress had 1177 participants, including rheumatologists from 29 out of 30 provinces in China. The questionnaire was sent to all participants. Each survey respondent rated a 20-question questionnaire voluntarily on their knowledge, attitude and practice regarding FM.
The study was carried out in compliance with current ethical standards for research with human subjects and was approved by the hospital institutional board. Eligible participants were verbally provided informed consent and then completed a questionnaire.
All data were analyzed using SPSS, version 16.0 (SPSS Inc., Chicago, IL, USA). Data were double-entered by two research assistants. The first step was to compare the respondents' demographic information with ensemble characteristics to evaluate the representativeness of the survey. Categorical variables were analyzed using Pearson's χ2 tests. For parametric comparisons, unpaired t-tests or analyses of variance (anova) were performed. Then descriptive analysis was used to estimate the awareness for different measures.
By the end of the congress, 707 completed questionnaires were collected. The response rate was 60.1%. The mean age of the participating rheumatologists was 38.6 ± 8.3 years and 411 of the respondents (58.1%) were female. The mean service time was 7.9 ± 6.5 years.
There were no statistically significant differences between the demographic characteristics of our samples and the overall data of rheumatologists in China, which showed the respondents were well representative of Chinese rheumatologists (Table 1).
Table 1. Demographic characteristics of the respondents compared to the general population of Chinese rheumatologists
Age (mean ± SD, years)
38.6 ± 8.3
39.4 ± 9.6
Composition of physicians (%)
Associate chief physicians
Clinical and educational experience of FM among rheumatologists
Nearly 80% (543/707, 76.7%) of participating rheumatologists had experience of diagnosing FM in clinical practice. However, 226 of these 543 (41.6%) respondents declared they had seen very few FM patients; 41.8% of them indicated that they saw 1–5 patients per month, 10.3% saw 5–10 patients per month, 2.5% saw 10–20 patients per month; only 3.7% handled more than 20 patients per month. No more than one-fifth of the respondents were experienced in dealing with FM. Compared to an average of roughly 800 patient visits per month per Chinese rheumatologist, the magnitude of FM patient load is therefore very low.
Among rheumatologists who had never diagnosed FM, only 23.8% of them had received continuing medical education on FM, compared with 62.4% in those who had ever diagnosed FM. These data indicated that continuing medical education had significant impact on the awareness of FM as an independent clinical entity. This could be partly due to a lack of medical school training programs on FM in China to-date.
Knowledge of FM
Nearly 70% (69.4%) of the respondents believed that FM was a distinct pathological entity. Although there is no distinctive tissue pathological change in FM, 233 (33.0%) respondents believed that FM was a disease characteristic with muscle inflammation. In contrast, 30.6% (216/707) of the respondents regarded FM as a psychological illness.
Among risk factors of FM, latent psychological illness was at the top of the respondents' lists (85.5%), followed by overpressure (81.4%), female (78.6%), senility (39.0%), environmental noise (30.6%) and trauma (29.0%).
Table 2 presents the main symptoms that Chinese rheumatologists considered to be characteristics of FM. Widespread pain (87.4%), fatigue (77.8%), sleep disturbance (74.4%) and emotional disorder (67.3%) were among the most frequently recognized symptoms.
Table 2. Distribution of correct responses regarding various clinical fibromyalgia (FM) characteristics
% of correct responses (n)
Widespread musculoskeletal pain
Minimal no. of tender points for diagnosis of FM
More prevalent in woman
Regarding diagnosis, 65.5% (463/707) of the respondents claimed to use the 1990 American College of Rheumatology (ACR) classification criteria in their clinics. Unfortunately, only 37.4% of the respondents knew the details of the criteria for FM. For example, only 54.9% of the respondents knew the minimal number of tender points needed for diagnosis. Among the rheumatologists (244/707) who did not use the ACR criteria, 85.2% (209/244) of them considered them too complicated to be applied in daily practice, 46.3% complained they were too difficult to handle, 18.9% of them thought the criteria were not reliable.
Practice in FM management
When asked about treatment modalities of primary FM, 71.8% of the respondents thought there was no effective therapy for FM, while 95.3% did prescribe medicines to patients. Most of the respondents (89.4%) believed that treatment should focus on relieving symptoms. The order of preferred treatment was anti-depressants (79.1%), followed by non-steroidal anti-inflammatory drugs (61.2%), physical therapy (56.0%) and exercises (52.6%). However, there were still 24.9% and 11.9% of respondents, respectively, who considered steroids and immunosuppressive agents were effective in primary FM, preferring to use them in their daily practice (Fig. 1).
Attitudes toward FM in practice
Nearly 80% (569/707) of the respondents declared they had difficulties in treating FM patients. When asked about the reasons, 32.7% (186/569) of respondents thought the existing treatments lacked effectiveness, 44.8% (255/569) worried about the side effects and 14.9% (85/569) were not confident in treating this disease.
Although 71.8% of respondents thought there was no effective therapy for FM, 72.6% of these believed they could successfully treat patients with FM. The contradictory answer may be partly explained by the respondents' attitudes to the prognosis. Results from the survey showed that 85.1% of respondents believed that FM prognosis was benign, 8.6% thought the prognosis was poor and 6.2% chose ‘it is hard to say’.
Knowledge and education degree compared with other countries
We used ‘fibromyalgia’, ‘rheumatologist’ and ‘survey’ as the key words for a literature search in PubMed. The literature published in English after 1990 were evaluated. The awareness, knowledge and management of FM were compared between rheumatologists in China and other countries[20, 21] (Table 3). From our data, Chinese rheumatologists' knowledge and level of education regarding FM were lower than colleges in France and South East Asian.
Table 3. Comparison of awareness, management and education of Chinese doctors regarding fibromyalgia (FM) and other countries
In China, there is so far no medical school training on FM. Our data showed most (54.9%) physicians obtained knowledge of FM from continuing medical education, such as online education. Other respondents acquired knowledge from books, journals and lectures through self-study. Ninety-four percent of the respondents were eager to participate in education programs on FM.
This is a relatively large-scale investigation of Chinese rheumatologists' perceptions of FM based on a 20-item questionnaire. The results show that FM is an under-recognized and underestimated problem in China. Chinese rheumatologists are not generally familiar with FM, which may account for low diagnostic rates and improper treatment of this disease. The results also indicate that medical school training and continuing medical education regarding FM are not sufficient at present. Chinese rheumatologists require further help to improve their knowledge and clinical skills regarding FM.
The definition and understanding of FM have evolved over time. Although great debate is still going on, there is increasing acceptance of FM as an independent entity due to understanding of the unique pathophysiological abnormalities involved in this disease.[22-24] However, only 70% of the respondents in our survey deemed that FM exists as a distinct clinical entity; 30% believed that it was a psychological illness. The results also show that 23% of respondents have never made a diagnosis of FM, which indicates that FM is somewhat ignored by some Chinese rheumatologists. FM is easy to recognize if one looks for it, but also easy to overlook if one does not. It appears that, for many respondents, testing for FM is not yet part of their routine examination repertoire.
The understanding of FM is of great importance in recognizing and diagnosing FM early to avoid patients' anxieties and frustrations. The 1990 ACR criteria defines FM as a history of chronic widespread pain, above and below the waist (including the whole length of the spine), and excessive bilateral tenderness when pressure is applied to 11 of 18 specific muscle-tendon sites. Although the majority of respondents recognized the characteristic symptoms of FM, it was disappointing to find that more than 10% of respondents did not know that musculoskeletal pain was a key element in the diagnosis of FM. As many as 33% of respondents confused FM with muscle inflammation diseases. Only half the respondents knew the exact number of tender points needed for diagnosis. Insufficiency in FM-related knowledge in rheumatologists would therefore lead to failure to recognize the presence of FM in their patients.
The survey was conducted before the new criteria were published; however, only more than 60% of the respondents accepted the 1990 ACR criteria, while only half of them knew exactly what the criteria were. They referred to the complexity of the criteria. Indeed, the ACR criteria were originally established as a classification criteria rather than a diagnostic criteria. Muscle tenderness examination is not useful for beginners in the field and is frequently incorrectly performed.[26, 27] Another shortcoming of the criteria is that it gives no indication of other clinical characteristic, such as sleep disturbance, but merely the widespread pain aspect of FM.[3, 28, 29] In our survey, 18.9% of the respondents thought the 1990 ACR criteria not reliable. It is hoped that the new criteria for the diagnosis of FM will be more helpful to clinicians. Knowledge of the new criteria has not been tested in Chinese rheumatologists. However, it is reasonable to conclude that continuing medical education regarding the new criteria is also required for clinicians to improve their clinical skills and health care standards for patients with FM.
Incorrect treatment may cause potential harm to patients. Unfortunately, we found that 24.9% and 11.9% of respondents respectively, thought steroids and immunosuppressive agents were effective for FM. It is urgent to improve skills in treating FM in rheumatologists who lack education in this disease. A Chinese edition with recommendations for FM management and education regarding optimal treatment protocols is essential for Chinese rheumatologists.
In the context of attitudes to treatment, a lack of confidence is common. Eighty-five percent of the respondents had difficulties in treating FM. The respondents' comments on treatment are not surprising. Therapeutic nihilism reflects the genuine difficulty in successfully alleviating FM symptoms. The effectiveness of conventional treatment in rheumatology is generally disappointing regarding FM. Many individuals do not benefit from currently available treatments; newer strategies are required. Optimism regarding FM prognosis may result from the lack of long-term follow-up of FM patients in clinical practice, and also the lack of consideration regarding the social or psychological consequences of this disease. Clinical research on patient physical function, quality of life and disease impact on social functions should be conducted to direct the management of FM in China.
There are several limitations of this survey. First, this study was cross-sectional in nature, and results were only obtained from respondents who were willing to take part in the survey. Selection factors might have led to a biased sample of highly motivated rheumatologists who might not reflect the general professional population. Second, the findings were limited to a self-report questionnaire and communication between respondents was not forbidden, although the questionnaire was anonymous. Third, statistical tests used were only descriptive analyses.
High-standard health care service depends on both easy access to specialists and awareness of particular conditions by specialists. An inspiring finding was nearly all respondents expressed interest in continuing medical education on FM, indicating there is still much room for Chinese rheumatologists to improve their perceptions and skills. This study lays the initial groundwork for further work. The findings of this survey call for major measures by health authorities to improve education regarding FM in China, consequently reducing the societal burden.
This study was kindly supported by the Chinese Rheumatology Association. We thank Professor Xiaoping Kang and Ms. Chunfang Zhang (Department of Epidemiology and Biostatistics, Peking University Health Science Center) for their statistical support. We also thank all participants for their enthusiasm and cooperation in this study.