30 Fibromyalgia


Fibromyalgia is used to describe a ‘constellation of symptoms’ characterized by widespread pain in the muscles and joints, fatigue, sleep problems and cognitive difficulties (Arnold et al., 2019).


The current scientific consensus is that symptoms are caused by ongoing neuro-inflammation and hyper-vigilance of the central nervous system. More specifically sustained glial cell activation and elevated levels of certain inflammatory substances (Albrecht et al., 2019). Symptoms are then exacerbated as the body struggles to dampen neuro-immune responses associated with pain, fatigue and cognitive difficulties.


A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient Specific Functional Scale
  • Brief Pain Inventory (BPI)
  • Visual Analog Scale (VAS)
  • Fatigue Severity Scale
  • Fibromyalgia Impact Questionnaire (FIQ)
  • Michigan Body Map
  • Perceived Stress Questionnaire (PSQ)
  • McGill Pain Questionnaire (MPQ)
  • Pain Self Efficacy Scale
  • Multidimensional Pain Inventory



Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

Ascribing a patient’s pain solely to a tissue-driven pain problem is often an oversimplification of a complex process. This insight provides us with an opportunity to re-frame our clinical models. Gently stretching the muscles, neurovascular structures, and investing fascia activates endogenous pain modulating systems that help to modulate neuro-immune responses (Espejo et al., 2018).

Self-Management Strategies

People who experience symptoms of fibromyalgia may benefit from a moderate amount of exercise or physical activity. A 2020 umbrella review suggests 30-60 minutes of aerobic exercise or strength training 2-3 times a week is an appropriate dose for people with fibromyalgia (Andrade et al., 2020). However, it is important to note that people may experience exercise-related side effects as they start up a new program.


Several clinical practice guidelines recommend the use of massage therapy as part of a multi-modal approach for patients with Fibromyalgia (Busse et al., 2017; Skelly et al., 2020). It is not suggested that massage therapy alone can control symptoms but can be utilized to help relieve pain & reduce anxiety when integrated with standard care.

Massage Sloth: Massage for Fibromyalgia

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for fibromyalgia based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

Albrecht, D. S., Forsberg, A., Sandström, A., Bergan, C., Kadetoff, D., Protsenko, E., … Loggia, M. L. (2019). Brain glial activation in fibromyalgia – A multi-site positron emission tomography investigation. Brain, behavior, and immunity, 75, 72–83. doi:10.1016/j.bbi.2018.09.018

Andrade, A., Dominski, F. H., & Sieczkowska, S. M. (2020). What we already know about the effects of exercise in patients with fibromyalgia: An umbrella review. Seminars in arthritis and rheumatism, 50(6), 1465–1480. https://doi.org/10.1016/j.semarthrit.2020.02.003

Arnold, L. M., Bennett, R. M., Crofford, L. J., Dean, L. E., Clauw, D. J., Goldenberg, D. L., … Macfarlane, G. J. (2019). AAPT Diagnostic Criteria for Fibromyalgia. The journal of pain: official journal of the American Pain Society, 20(6), 611–628. doi:10.1016/j.jpain.2018.10.008

Busse, J. W., Craigie, S., Juurlink, D. N., Buckley, D. N., Wang, L., Couban, R. J., … Guyatt, G. H. (2017). Guideline for opioid therapy and chronic noncancer pain. CMAJ: Canadian Medical Association journal, 189(18), E659–E666. doi:10.1503/cmaj.170363

Dailey, D. L., Vance, C., Rakel, B. A., Zimmerman, M. B., Embree, J., Merriwether, E. N., Geasland, K. M., … Sluka, K. A. (2020). Transcutaneous Electrical Nerve Stimulation Reduces Movement-Evoked Pain and Fatigue: A Randomized, Controlled Trial. Arthritis & rheumatology (Hoboken, N.J.), 72(5), 824–836. https://doi.org/10.1002/art.41170

de Oliveira, F. R., Visnardi Gonçalves, L. C., Borghi, F., da Silva, L., Gomes, A. E., Trevisan, G., … de Oliveira Crege, D. (2018). Massage therapy in cortisol circadian rhythm, pain intensity, perceived stress index and quality of life of fibromyalgia syndrome patients. Complementary therapies in clinical practice, 30, 85–90. doi:10.1016/j.ctcp.2017.12.006

Espejo, J. A., García-Escudero, M., & Oltra, E. (2018). Unraveling the Molecular Determinants of Manual Therapy: An Approach to Integrative Therapeutics for the Treatment of Fibromyalgia and Chronic Fatigue Syndrome/Myalgic Encephalomyelitis. International journal of molecular sciences, 19(9), 2673. doi:10.3390/ijms19092673

Skelly, A.C., Chou, R., Dettori, J.R., Turner, J.A., Friedly, J.L., Rundell, S.D., … Ferguson, A.J.R. (2020). Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update. Agency for Healthcare Research and Quality (US). DOI: https://doi.org/10.23970/AHRQEPCCER227

Sluka, K. A., & Clauw, D. J. (2016). Neurobiology of fibromyalgia and chronic widespread pain. Neuroscience, 338, 114–129. https://doi.org/10.1016/j.neuroscience.2016.06.006

Mascarenhas, R. O., Souza, M. B., Oliveira, M. X., Lacerda, A. C., Mendonça, V. A., Henschke, N., & Oliveira, V. C. (2020). Association of Therapies With Reduced Pain and Improved Quality of Life in Patients With Fibromyalgia: A Systematic Review and Meta-analysis. JAMA internal medicine, e205651. Advance online publication. https://doi.org/10.1001/jamainternmed.2020.5651

Nadal-Nicolás, Y., Rubio-Arias, J. Á., Martínez-Olcina, M., Reche-García, C., Hernández-García, M., & Martínez-Rodríguez, A. (2020). Effects of Manual Therapy on Fatigue, Pain, and Psychological Aspects in Women with Fibromyalgia. International journal of environmental research and public health, 17(12), 4611. https://doi.org/10.3390/ijerph17124611

Prabhakar, A., Kaiser, J. M., Novitch, M. B., Cornett, E. M., Urman, R. D., & Kaye, A. D. (2019). The Role of Complementary and Alternative Medicine Treatments in Fibromyalgia: a Comprehensive Review. Current rheumatology reports, 21(5), 14. doi:10.1007/s11926-019-0814-0

Yuan, S. L., Matsutani, L. A., & Marques, A. P. (2015). Effectiveness of different styles of massage therapy in fibromyalgia: a systematic review and meta-analysis. Manual therapy, 20(2), 257–264. https://doi.org/10.1016/j.math.2014.09.003


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Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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