Physical Therapist's Guide to
A chronic condition that is often difficult to diagnose, fibromyalgia affects almost 5 million people in the United States; 80% to 90% are women. Fibromyalgia usually is diagnosed in adults between the ages of 30 and 50, but the symptoms—such as widespread chronic pain and fatigue—can show up earlier.
Although there is no definitive cure at this time, there are treatments that can help. Your physical therapist can help you:
- Understand and manage your pain.
- Reduce your fatigue.
- Improve your function and quality of life.
What is Fibromyalgia?
The cause of fibromyalgia is unknown, but it's thought to be due to changes in how the nervous system processes pain. It might be triggered by trauma, surgery, infection, arthritis, or major emotional stress, or it may develop gradually over time. People with conditions such as rheumatoid arthritis, systemic lupus erythematosis, or ankylosing spondylitis are more likely to develop fibromyalgia.
The American Physical Therapy Association launched a national campaign to raise awareness about the risks of opioids and the safe alternative of physical therapy for long-term pain management. Learn more at our #ChoosePT page.
Signs and Symptoms
Fibromyalgia isn't just 1 condition; it's a complex syndrome involving many different signs and symptoms. With fibromyalgia, you may experience:
- Widespread pain, often a dull achiness, on both sides of the body above and below the waist
- Spots on your head, neck, chest, shoulders, elbows, hips, or knees that are tender to a firm touch; these “tender points” may move around or come and go
- Muscle stiffness, especially in the morning
- Thinking and memory problems
- Pain or cramps in the abdomen or pelvis
- Irritable bowel syndrome
- Irritable bladder syndrome
- Difficulty sleeping; waking unrefreshed
- Temporomandibular (jaw joint) pain
- Numbness or tingling
Often, stress can make your symptoms worse.
How Is It Diagnosed?
Because there are no blood tests, x-rays, or muscle biopsies that can be used to diagnose fibromyalgia, you’ll need to work closely with your health care providers to obtain an accurate diagnosis. Many conditions can cause pain and fatigue, so it's important to have a thorough medical examination to rule out conditions other than fibromyalgia, such as rheumatologic or infectious disease, Lyme disease, hypothyroidism, metabolic disease, or side effects due to medication.
Once other conditions have been ruled out, a diagnosis is made based on key symptoms—extreme fatigue, pain in multiple "tender points" (points that are tender to touch and that move around), trouble sleeping, anxiety, and memory problems. Your physical therapist can identify fibromyalgia while performing a routine examination and taking your health history. Your therapist will pay close attention to the pattern of your symptoms. For instance, there are 18 possible tender points, and the more tender points you have, the more likely you have fibromyalgia. The therapist may refer you to a rheumatologist, a physician who specializes in arthritis, for medical care that includes medications.
How Can a Physical Therapist Help?
Living with fibromyalgia can be challenging. Your pain and other symptoms might take different forms from day-to-day. If you avoid activity because of pain, your overall physical fitness might be decreased.
Extensive research supports the use of education, aerobic exercise, and strengthening exercise to help improve fibromyalgia. But fear of pain often keeps people from beginning an exercise program. Your physical therapist will teach you how to interpret pain signals—and how to manage and decrease your symptoms—through a customized exercise program.
Help You Take Control Through Information
Research shows that people who are knowledgeable about their health condition have more confidence, can cope better with their condition, and are more likely to get "back in the swing." Your physical therapist can explain how fibromyalgia affects the way your body perceives and responds to pain and how you can start to take control of the pain, rather than the pain controlling you. We also have evidence to support that knowledge is power, as it pertains to managing pain. There are several books, such as Why Do I Hurt, that have helped people in pain.
Your therapist also can provide information on local support groups, exercise programs, and self-help programs.
Manage Your Symptoms Through Exercise
Regular, moderate exercise is an important part of managing fibromyalgia. Reducing body mass index can actually reduce the risk of developing fibromyalgia.
Research has shown that the following treatments can decrease pain and improve function, general health, and sleep in people with fibromyalgia:
- Aerobic conditioning
- Aquatic exercise
- Strengthening exercise
- Tai chi
- Deep breathing
- Recreational activities
- Manual therapy
Your physical therapist will design an exercise program that’s right for you. To ensure your success, the therapist will show you how to:
- Start slow.
- Pace yourself.
- Set realistic goals for exercise and physical activity.
- Modify your program in times of stress.
Your physical therapist can help you improve not only your fitness, but your quality of life by designing a program of aerobic exercise, which trains your heart and lungs as well as your muscles. Aerobic exercises include walking briskly (you can talk but you need to take deep breaths), bicycling, swimming, and using a stair-climbing or elliptical device.
If you have severe symptoms, your physical therapist will work with you to gradually increase your overall activity level and your tolerance for exercise, starting you off with exercises that you are able to perform for short periods (eg, 10 minutes), and then gradually building up your tolerance for longer exercise. Even short, 10-minute exercise sessions done 2 or 3 times per day can improve your strength and increase your endurance. If you have milder symptoms, the therapist might focus on strengthening your muscles or increasing your cardiovascular fitness. The therapist might recommend aquatic exercise in a pool to help reduce stiffness and pain while you exercise.
Even if you start out slowly, you are likely to have more pain as a result of increasing your activity. Your physical therapist will prepare you by teaching you techniques that you can use at home, such as relaxation techniques and stretching exercises.
You might have other conditions in addition to fibromyalgia, such as tendinitis, arthritis, or heart disease. These conditions can make exercise more difficult for you. Your physical therapist is uniquely trained to individualize treatment for those conditions, taking into consideration the effect that they might have on your fibromyalgia symptoms and on your exercise ability.
You may be prescribed medications that target brain chemicals that are responsible for the way your body deals with pain. Physical therapists also take into account the effects that medications may have on your movement and exercise ability.
Improve Your Range of Motion
Your therapist may use manual therapy techniques to move your joints while you are relaxed to help improve your joint motion. These techniques are combined with exercise, stretching, and movements that you control.
Use Special Techniques
Research indicates that the best results are likely to come from combining a variety of treatments. Appropriate medications, exercise, and "mind-body techniques" can work together to help you manage your symptoms.
Some techniques, such as meditation and cognitive behavioral therapy, can change your responses to pain and promote relaxation. Physical therapists also are educated and experienced in how to recognize behaviors that may interfere with recovery of function, and often refer patients to other health care professionals who can help them overcome these barriers.
Your physical therapist might use biofeedback to help you control muscle tension and decrease pain, using a device that provides you with information about the amount of tension in your muscles. The therapist places electrodes on your skin with a soft gel, and these electrodes record muscle tension while your therapist explains how you can relieve that tension.
Your therapist also can show you how to set a routine time for sleeping and waking to allow for good restorative sleep. The therapist will discourage you from sleeping in the daytime, as that can throw off your sleep cycle.
Reduce Your Pain
To reduce your pain, your physical therapist may select from a number of treatments:
- Your therapist may use pressure on specific areas of the muscle, followed by stretching or contracting your muscles, to relieve pain and make the muscles more flexible. Your therapist also might use manual therapy techniques to help relieve pain in your muscles and other connective tissues (the material between the cells of the body that support the organs and other tissues).
- In states where it is allowed by the physical therapist practice act, your therapist might use an approach called "dry needling" to relieve your pain by inserting very fine wire-like needles into the painful areas of the muscle.
- Massage therapy can be used to increase blood flow to the tissues and promote muscle relaxation to decrease muscle pain and stiffness, and break up scar tissue.
- Depending on the severity of your pain, your therapist might decide to use electrical stimulation to help relieve pain. Some people find that portable electrical stimulation devices help them manage severe pain independently. Your physical therapist will work with you to help determine if this type of treatment makes sense for you.
Can this Injury or Condition be Prevented?
Unfortunately, the actual mechanisms behind fibromyalgia are not completely understood. Because of this, there is no way to predict or to prevent its onset. However, early detection of signs and symptoms related to fibromyalgia will help you and your medical providers begin early management, which may enhance your long-term outcomes.
Real Life Experiences
Claire J. is a 32-year-old woman who has been struggling to get up each morning to get her 2 young children off to school. She has extreme fatigue, trouble remembering things ("I frequently misplace my eye glasses and purse"), and muscle pain and stiffness that seem to move around her body. The symptoms began suddenly and have persisted for 5 months. Her primary care physician is concerned that she might be depressed. He prescribes an antidepressant and refers her for physical therapy.
Claire's physical therapist conducts a full physical examination and musculoskeletal testing and notes that she has 11 out of a possible 18 tender points, general fatigue, and muscle stiffness. The therapist recommends that Claire see a rheumatologist for medical management and starts her on a program of gentle stretching exercises, paced walking, and meditation using yoga. In addition, Claire and the therapist discuss a sleep hygiene routine and a sleep log, in which Claire will record her sleep patterns over the coming months.
The rheumatologist prescribes medication for Claire, and she continues her gentle stretching and exercise program. She begins sleeping 6 or 7 hours per night. The physical therapist then develops a gentle aerobic exercise program, which Claire says improves her fatigue once she gets herself motivated to do the exercise.
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat people who have fibromyalgia. You may want to consider:
- A physical therapist who is experienced in treating people with fibromyalgia or musculoskeletal problems.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopaedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist:
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapist's experience in helping people with fibromyalgia.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following research articles provide some of the best scientific evidence about physical therapist treatment of fibromyalgia. The articles report recent research and give an overview of the standards of practice for treatment of fibromyalgia both in the United States and internationally. Whenever possible, the article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Nijs J, Mannerkorpi K, Descheemaeker F, Van Houdenhove B. Primary care physical therapy in people with fibromyalgia: opportunities and boundaries within a monodisciplinary setting. Phys Ther. 2010;90:1815–1822. Free Article.
Brosseau L, Wells GA, Tugwell P, et al. Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: Part 1. Phys Ther. 2008;88:857-871. Free Article.
Brosseau L, Wells GA, Tugwell P, et al. Ottawa Panel evidence-based clinical practice guidelines for strengthening exercises in the management of fibromyalgia: Part 2. Phys Ther. 2008;88:873-886. Free Article.
Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004;292:2388–2395. Free Article.
Busch AJ, Barber KA, Overens TJ, et al. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007;(4):CD003786. Article Summary on PubMed.
Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008;67:536–541. Article Summary on PubMed.
Jones KD, Adams D, Winters-Stone K, Burckhardt CS. A comprehensive review of 46 exercise treatment studies in fibromyalgia (1988–2005). Health Qual Life Outcomes. 2006;4:67. Free Article.
National Arthritis Foundation
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.
Revised by Joseph Brence, PT, DPT. Authored by Dana Dailey, PT, MS; Holly Burt, PT, DPT; Cindy Maurer, PT, DPT, board-certified clinical specialist in orthopaedic physical therapy; and Maura Daly Iversen, PT, DPT, MPH. Reviewed by the editorial board.