Introduction 

Fibromyalgia is a chronic condition that is characterised by musculoskeletal pain throughout the body, fatigue, sleep and mood disturbances, and cognitive difficulties involving concentration, memory, and experiencing brain fog. This impacts one’s daily life and their ability to carry out activities like lifting, carrying, holding things, and walking, to name a few. People assigned female at birth are diagnosed with fibromyalgia more often than people assigned male at birth. Individuals experience a low quality of life because of physical pain and the inability to live actively.¹ 

Pain in fibromyalgia can vary from headaches, stomach cramps, and joint pain. It can be distressing and affect various aspects like work, social life, and relationships. There is no cure for fibromyalgia, but research has shown that physical therapy can improve pain, stiffness, and movement.

Goals of physical therapy in fibromyalgia 

You might discuss your goals with your physiotherapist or a related healthcare professional (HCP) regarding what you want to achieve with physical therapy. Common goals include: 

• Pain management 
• Improving mobility and flexibility 
• Increasing strength 
• Boosting daily functioning 

Assessments carried out before starting physical therapy

Healthcare professionals (HCPs) usually ask for some information before starting treatment. They may take: 

• Detailed medical history of past and present health conditions, medications, and previous treatments
• Physical examination to identify areas of pain, range of motion, muscle strength, and posture
• Functional assessments to check the ability of the individual to do certain tasks like walking, climbing stairs, lifting, etc
• Psychological assessments for anxiety, depression, trauma, and sleep disturbances 

These assessments are important as they help to tailor treatments to the individual’s needs. It also helps to identify any potential risks and limitations to consider during exercise. 

Assessments act as a comparison point that allows HCPs to track progress during treatment and make any necessary changes. Moreover, HCPs guide how to set realistic and achievable goals. 

Types of physical therapy interventions 

Exercise therapy 

Research has shown that aerobic exercise (AE), such as walking, swimming, cycling, jogging, and dancing, can improve pain, tiredness, depression, physical fitness, and the health-related quality of life (HRQOL).² There is no difference in superiority between land-based exercises and water-based ones, but having a combination of various exercises can help. One should do AE 2-3 times a week for a duration of 4-6 weeks to see a reduction in their symptoms.² 

The type and amount of exercise should be discussed with HCPs to carry out activities safely. Sometimes, there can be discomfort when starting any exercise. It usually improves with time and with consistency. You should consult your physician before beginning any intervention. 

Manual therapy 

Manual therapy is a technique where physiotherapists use their hands to gently move, massage, stretch, or position your joints and muscles. It reduces pain, improves movement, corrects posture, boosts circulation, and reduces tightness or stiffness when performed correctly by a healthcare professional qualified in fibromyalgia. It is an alternative form of treatment and not a standalone intervention. 

Most healthy people find manual therapy more helpful than people with fibromyalgia because the body is more sensitive to touch and movement in fibromyalgia.³ Massage therapy can be painful to some more sensitive individuals, but statistics show that 75% of individuals with fibromyalgia undergo massage therapy as they prefer the long-term benefits in managing pain.⁴ Research also shows that massage therapy can improve pain, sleep quality, anxiety, and depression.⁵ These results show after 5 or more weeks of massage therapy.⁶ 

Aquatic therapy 

Aquatic therapy, also known as hydrotherapy, can be an effective way to manage fibromyalgia symptoms, especially pain and psychological distress. This treatment is done in water. The properties of water, like its buoyancy (this is the water’s ability to push objects above), make it a unique and ideal environment to practice exercises for improving joint mobility and muscle strengthening with less effort and stress. Research shows that it improves pain, quality of life, depression, and anxiety.⁷ 

This therapeutic modality applies safe and easy-to-do movements, making it attractive for those individuals who dislike exercise (exercise rejection). There must be supervision from a qualified practitioner guiding the sessions. If there is no access to swimming pools, it might be harder to implement this intervention. 

Pain management techniques

Heat therapy 

Heat therapy is the process of applying heat to affected areas to relieve pain. It is commonly used and safe for fibromyalgia pain. Applying heat to an area increases blood flow to that area, which helps with pain, reduces stiffness, and relaxes the muscles. This is why hot showers can help you feel more relaxed.

Research has also found that immersing oneself in hot water for 45 minutes over a period of 4 weeks can significantly improve pain, sleep, physical function, and fatigue.⁸ Historically, heat therapy in the form of saunas and baths has improved quality of life and overall well-being in people, while also improving various areas of physical health like blood pressure, heart problems, and chronic pain.^9,10 

Transcutaneous electrical nerve stimulation (TENS)

TENS is a device with electrode pads that are placed on the skin of the area with pain, and a tiny electrical current is sent between two pads. This works to reduce the pain signals produced by your muscles below the pads. The device lets you or the HCP control the intensity of the stimulation signal. Some areas, like your neck, might require less stimulation, and some areas, like thighs and hips, may require more. It is a safe and non-pharmacological (non-drug) method to reduce pain in fibromyalgia. 

It is by no means a treatment, but an intervention to reduce the intensity of pain. Moreover, it does not reduce pain long-term but gives a more short-term immediate benefit.¹¹ Some people find TENS relaxing and helpful.

Relaxation and breathing techniques 

Relaxation, meditative, and breathing techniques reduce muscle tension, pain sensitivity, and stress levels, calming the body and mind, which is especially important for people with fibromyalgia. The psychological and emotional burden of fibromyalgia must also be taken into account when treating individuals. Breathing exercises can improve pain, fatigue, and the ability to perform daily activities if performed regularly.¹³

Progressive muscle relaxation is a method of reducing tension in the muscles. It involves concentrating on a certain group of muscles, consciously tensing them, and then relaxing them again. This is repeated with different groups of muscles, for example, from head to toe, until the whole body feels relaxed.¹² This can be learned from videos, audios, or directly from an HCP who will guide the process. Pain, fatigue, perceived stress, blood pressure, and heart rate have all been improved by practicing this relaxation method for a period of about 8 weeks.¹⁴

Mindfulness-based stress reduction (MBSR) is also widely studied and proven to be effective in managing fibromyalgia. It uses mindfulness-based activities (mindfulness walking, eating, yoga), education, and breathing exercises for individuals to better respond to their pain, stress, and illness. Symptoms of depression have been significantly improved in people assigned female at birth who undergo mindfulness training.¹⁵ 

Challenges and considerations 

Individuals with fibromyalgia are a lot more sensitive to pain and physical movement. Physical therapy must be carefully planned and executed with flexibility. A few things to look out for: 

Sensitivity to overexertion

Fibromyalgia makes even mild activities difficult. Exercises can sometimes flare up pain and other symptoms, making it harder to stick to them in the long run. One can start with slow, gentle, and paced exercises to avoid overexertion, fatigue, and intense pain. 

Adapting sessions for flare-up days

On days when there is more than usual pain and tiredness, the physiotherapist can replace some difficult exercises with gentle stretching, relaxation, and breathing techniques. This way, there is consistent movement without causing too much strain. 

Consistency and patience

Physiotherapy exercises require consistent practice and time to see the results. Maintaining a steady schedule without skipping sessions regularly is important. 

Lifestyle changes

Physical therapy, along with healthy changes to diet, sleep schedule, and stress management, is key to making lasting and impactful changes. 

Other coexisting conditions

Other conditions, such as arthritis, chronic fatigue, or depression, can influence one’s treatment choices. Interventions should be according to one’s motivation, needs, and goals. In fibromyalgia, it is crucial to provide mental health support along with physiotherapy, as a lot of individuals struggle emotionally with the illness. 

Summary

Fibromyalgia is a chronic condition that is characterised by widespread pain throughout the body, fatigue, and mental health issues. Pain in the muscles and joints makes daily activities a lot harder to do. Hence, physiotherapy, like exercising, aquatic therapy, and relaxation techniques, can improve pain, fatigue, and the ability to carry out daily tasks. 

Individuals with fibromyalgia are a lot more sensitive to movement and exercise. Therefore, guided, slow, and gentle exercises are crucial in avoiding flare-ups and pain. Consistency is a key factor in seeing a reduction of symptoms and overall well-being.