Efficacy of Nonpharmacological Interventions for Individual Features of Fibromyalgia

A Systematic Review and Meta-analysis of Randomised Controlled Trials

Burak Kundakci; Jaspreet Kaur; Siew Li Goh; Michelle Hall; Michael Doherty; Weiya Zhang; Abhishek Abhishek


Pain. 2022;163(8):1432-1445. 

In This Article

Abstract and Introduction


Fibromyalgia is a highly heterogeneous condition, but the most common symptoms are widespread pain, fatigue, poor sleep, and low mood. Nonpharmacological interventions are recommended as first-line treatment of fibromyalgia. However which interventions are effective for the different symptoms is not well understood. The objective of this study was to assess the efficacy of nonpharmacological interventions on symptoms and disease-specific quality of life. Seven databases were searched from their inception until June 1, 2020. Randomised controlled trials comparing any nonpharmacological intervention to usual care, waiting list, or placebo in people with fibromyalgia aged >16 years were included without language restriction. Fibromyalgia Impact Questionnaire (FIQ) was the primary outcome measure. Standardised mean difference and 95% confidence interval were calculated using random effects model. The risk of bias was evaluated using the modified Cochrane tool. Of the 16,251 studies identified, 167 randomised controlled trials (n = 11,012) assessing 22 nonpharmacological interventions were included. Exercise, psychological treatments, multidisciplinary modality, balneotherapy, and massage improved FIQ. Subgroup analysis of different exercise interventions found that all forms of exercise improved pain (effect size [ES] −0.72 to −0.96) and depression (ES −0.35 to −1.22) except for flexibility exercise. Mind–body and strengthening exercises improved fatigue (ES −0.77 to −1.00), whereas aerobic and strengthening exercises improved sleep (ES −0.74 to −1.33). Psychological treatments including cognitive behavioural therapy and mindfulness improved FIQ, pain, sleep, and depression (ES −0.35 to −0.55) but not fatigue. The findings of this study suggest that nonpharmacological interventions for fibromyalgia should be individualised according to the predominant symptom.


Fibromyalgia is a common condition affecting 2% to 8% of the general population.[45] It manifests with multiple regional pain and other symptoms such as fatigue, low mood, nonrestorative sleep, and cognitive dysfunction.[201,202] It has a substantial impact on quality of life (QoL)[87] and results in a 5-fold higher health-care expenditure.[23] Its diagnosis and management are often challenging because of heterogeneous manifestations and differences between individuals with respect to dominant symptoms.[113,194]

Nonpharmacological interventions are recommended as the first-line treatment for fibromyalgia in multinational recommendations.[61,114] However, a comprehensive systematic review (SR) of all nonpharmacological interventions has not been conducted to-date and the recommendations about the use of nonpharmacological interventions in the EULAR evidence-based recommendations were based on a review of SRs published between 2008 and 2015.[114] Since then, a number of randomised controlled trials (RCTs) have been published, and the evidence needs updating to better inform clinical practice. Moreover, the disease characteristics that predict response to different nonpharmacologic therapies are poorly understood, and further research in this field is needed.[114] Lack of knowledge about these factors limits the ability to personalise nonpharmacological management of fibromyalgia.

Thus, the objectives of this study were to assess the efficacy of all nonpharmacological interventions, including different types of exercise and psychological therapies on disease-specific QoL, and 4 common manifestations of fibromyalgia, pain, fatigue, sleep, and depression that were ranked as key symptom domains for fibromyalgia by an Outcome Measures in Rheumatology Clinical Trials (OMERACT) working group.[125]