An estimated 10 million Americans are living with fibromyalgia, according to data from the National Fibromyalgia Association. While women are disproportionately affected by this disorder, with as much as 75 to 90% of people living with fibromyalgia being women, it also occurs in men and children.

The primary symptom of fibromyalgia is chronic widespread pain. Other common symptoms include fatigue, mood disorders (e.g., anxiety and depression) and sleep disturbances. Although regular exercise elicits a wide range of health benefits, it can aggravate or worsen fibromyalgia symptoms if it is not individualized and performed properly. This, in turn, may lead to greater inactivity and decreased conditioning, which can spiral into an increased risk of obesity and other comorbidities that further increase pain and significantly diminish the individual’s overall quality of life.

For these reasons, it is critical that you understand the unique needs of this vulnerable population. In this article, we share lessons gleaned from years of experience working with individuals who have fibromyalgia and offer guidance on how you can develop safe and effective exercise programs for your clients who may be dealing with this health challenge.

Conditions Often Associated With Fibromyalgia

It has been reported that more than half of individuals with fibromyalgia often have other comorbidities as well. The most common other chronic conditions include:

  • Depression (71.5%)
  • Chronic join pain/degenerative arthritis (88.7%)
  • Chronic headaches (62.4%)
  • Insomnia (50.6%)
  • Metabolic syndrome (50.5%)
  • Obesity (48%)

Exercise is relatively safe for most clients who have multiple chronic conditions, provided that appropriate assessment and screening is performed prior to beginning the program. The likelihood of an adverse event, although not entirely preventable, can be significantly reduced with baseline assessments, education and client adherence to established exercise recommendations. Always take the time to check in with your client’s entire medical team about any specific limitations to be aware of when designing the exercise program.

Common MedicationExercise Response Considerations

The medical management of fibromyalgia may include a broad range of medications. Because individuals who have fibromyalgia often have comorbidities, such as metabolic syndrome and depression, it is paramount that you understand the interaction of certain medications with the exercise response and how the exercise program might need to be modified. Given the multicomponent risk factor nature of metabolic syndrome, the considerations for medication–exercise response interactions and resulting exercise program modifications for clients with metabolic syndrome are more pronounced relative to most other conditions and/or diseases. Please take a look at the linked article for some of the key considerations.

Clients with fibromyalgia are also likely to be taking selective serotonin reuptake inhibitors (SSRIs) to manage depression stemming from the disorder. For example, one study reported that 28.7% of fibromyalgia patients were prescribed SSRIs (selective serotonin reuptake inhibitors). This category of medications can have some notable effects on exercise, including hypotension and fatigue. Accordingly, you may need to make the necessary adjustments to your clients’ programs, such as including a prolonged cool-down and reducing overall training intensity and volume to account for these medication–exercise response considerations.   

The intent of this section is not to be exhaustive in its scope, but rather to underscore the importance of being aware that medications can affect a client’s response to exercise and should be considered when designing their program. It’s also critical to collaborate with the multidisciplinary team of medical providers who manage your client’s fibromyalgia and familiarize yourself with other relevant medications and considerations for overall exercise programming.

Three Rules of Program Design for Clients Who Have Fibromyalgia

Three overarching rules should guide your program design for clients who have fibromyalgia:

  1. Educate and build trust.
  2. Progress slowly.
  3. Adapt every exercise session to symptom severity.

Initially, help your clients understand that, at least for the first several weeks of a new exercise program, they may likely experience more pain and fatigue. These symptoms tend to be slightly delayed and transient and will not show up for one to two days after exercise. As such, doing too much too quickly is a recipe for disenchantment with exercise, especially if your client doesn’t know what to expect. However, if you explain to your client that their symptoms might actually get somewhat worse at the beginning of their program, but reassure them that symptoms will gradually get better across subsequent weeks, their trust in you will increase and they will be more likely to adhere to their program. It may also be helpful to show your fibromyalgia clients research demonstrating that regular cardiorespiratory and muscular training reduce pain and improve overall well-being, as they might have been mistakenly told to avoid exercise.

Given the reality that most fibromyalgia clients will initially be deconditioned, as well as the likelihood that symptoms might get worse before they get better, progressing slowly is critical. Exercise should commence at very light intensities [i.e., less than 30% of heart-rate reserve (HRR)] and, as tolerated, gradually increase to light (30 to 39% HRR) and moderate intensities (40 to 59% HRR). The rating of perceived exertion (RPE) scale is a great method for clients to self-monitor intensity, as people with fibromyalgia report a higher RPE for the same relative workload when compared to matched individuals without fibromyalgia. This is especially true during flare-ups in pain and/or fatigue. Exercise can start at low durations of five to 10 minutes, with recovery breaks in between, and gradually increase by five minutes per session each week as energy levels and symptoms permit.   

Fibromyalgia can be an extremely diverse and unpredictable condition, which means that no two clients will be the same with respect to the type and severity of their symptoms. In fact, symptoms such as pain and stiffness can fluctuate considerably from day to day and even within the course of a given day. For these reasons, it is important to be fluid with your exercise programming. For instance, some days may require more rest between exercises. Or, it might be necessary to program upper- and lower-body muscular training exercises across separate days. Additionally, it can be valuable to familiarize yourself with the 18 tender points of fibromyalgia, as this can be important in the selection and avoidance of specific exercises. For example, if a client has painfully tender gluteal points, cardiorespiratory exercises such as walking or aquatic exercise would be better choices than riding an exercise bike or using other seated cardio equipment.

Follow the ACE Integrated Fitness Training® (ACE IFT®) Model Guidelines With Special Considerations

In general, you can use the ACE Integrated Fitness Training (ACE IFT) Model guidelines for cardiorespiratory and muscular training with your clients with fibromyalgia. However, there are a number of special programming considerations to keep in mind:

  • For cardiorespiratory training, prioritize increasing exercise duration relative to intensity. For muscular training, prioritize lighter resistance and more repetitions.
  • The talk test is a practical way to identify ventilatory thresholds and helps to provide individualization to cardiorespiratory training. In our experience, clients with fibromyalgia find using the ability to talk comfortably to be the easiest way to regulate their intensity and avoid aggravating symptoms throughout exercise sessions.
  • Remind clients to limit or avoid exercise during periods of acute flare-ups and worsening of symptoms. The Revised Fibromyalgia Impact Questionnaire can help clients identify their individual fibromyalgia-related symptoms and how they might impact various activities of daily living and their ability to perform physical activity and exercise.
  • Terminate exercise if your client expresses pain that is too severe to continue. While we recommend using a threshold of 4 on the perceived discomfort scale (RPE-D), this can vary from client to client.   
  • Aquatic exercise in warmer water (i.e., 91 to 97° F or 33 to 36° C) is an excellent exercise modality option given its muscle-relaxing and analgesic properties.
  • Providing social support and encouraging exercise in a group setting can be helpful with promoting exercise adherence.

The ACE Mover MethodTM in Action: Help Fibromyalgia Clients Navigate Their Heat-Cold Intolerances

Intolerance to temperature extremesboth heat and coldis a problem encountered by many fibromyalgia clients. In view of this, we cannot emphasize enough how critical it is to be mindful of the very likely potential for considerable worsening of various fibromyalgia symptoms with temperature fluctuations. We often use the ACE Mover Method to help problem-solve the challenge of temperature intolerances with our clients. Since no two individuals with fibromyalgia are alike, it’s important to ask your clients various open-ended questions to get a sense for what specific types of environmental conditions trigger which specific symptoms. For example, you might ask a client one or more of the following questions:

  • Do you have trouble with your fatigue during heat waves?
  • Is there a specific temperature that seems to really elicit a marked worsening in your energy levels?
  • Does cold weather exposure cause an increase in pain?

As a health and exercise professional, you can next help identify barriers and collaborate with your clients to ensure positive outcomes. For instance, it might be necessary to adjust the timing of outdoor exercise sessions to avoid the times of day when it will be hottest or coldest. Finally, partner with your clients by providing education on topics such as proper hydration practices and smart clothing choices. Utilizing the ACE Mover Method can help you and your clients navigate their temperature intolerances and remain regularly physically active.


Working with clients who have unique health conditions such as fibromyalgia can be challenging, yet highly rewarding. By understanding the condition and the impact that certain medications may have on exercise response, being mindful of special exercise programming considerations and utilizing the ACE Mover Method, you can set your clients up for success by helping them perform regular exercise safely and effectively while minimizing their fibromyalgia symptoms.

Expand Your Knowledge

A Holistic Approach to Mental Health

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