Back Pain Doctor
Fibromyalgia (Chronic Widespread Pain)
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Fibromyalgia is a real and often disabling condition, and its cause is not yet known. Assessment starts with listening to the whole picture: where pain is, how sleep and energy are, what mood and stress look like, and what has and has not helped. Blood tests are used to exclude other conditions, and a separate regional problem such as a rotator cuff tendon or a hip bursa is identified if it is also present, because treating that can ease part of the load.
First-line care is education, a graded exercise programme and attention to sleep. Exercise is the one treatment with a strong recommendation in the European guideline, and the best-supported approach is to start at a manageable level, progress slowly, and plan for flare-ups so that one bad week does not end the programme. Psychological support for mood, pain coping and sleep is a standard part of the plan, and medicines may be tried for severe pain or poor sleep, with the realistic expectation that benefit is modest and not guaranteed.
Care here means assessment, ruling out other causes, and a rehabilitation plan matched to the person’s capacity, working with their GP and, where needed, a rheumatologist, psychologist or pain specialist. Procedures and devices such as shockwave, dry needling or magnetic stimulation do not replace this plan: the sham-controlled evidence is limited, short-term and low in certainty, and patients who ask about them are told so. This page is for general education and does not replace an individual assessment.
Common symptoms
- Pain on both sides of the body, above and below the waist, lasting months or longer
- Fatigue and sleep that does not feel refreshing
- Difficulty concentrating or remembering, sometimes called fibro fog
- Tenderness, stiffness and flare-ups that vary with stress, poor sleep and overexertion
Evidence for twelve treatment options in fibromyalgia (chronic widespread pain)
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation: diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Strongest guideline recommendation
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan, with weight management where that is clinically relevant.
What the evidence shows
Exercise is the one therapy with a strong recommendation in the EULAR revision, which reviewed 107 systematic reviews and meta-analyses (Macfarlane, Ann Rheum Dis 2017). A 2026 network meta-analysis of 21 randomised trials (1,638 people) found aerobic, resistance and mind-body exercise each improved pain or fatigue versus routine care (Pan, Pain Res Manag 2026), and a 2026 systematic review of six trials found aerobic and resistance exercise both improved pain and quality of life with no consistent difference between them (de Freitas, Pain Manag Nurs 2026). Medicines give modest benefit at best: a Cochrane review of 18 trials (7,903 people) found no clinically relevant advantage of duloxetine or milnacipran at 50 per cent pain relief (Welsch, Cochrane 2018).
Pairing reviewed 2026-10-11.
Where it fits
Where care starts: education, graded exercise started low and progressed slowly, with a plan for flare-ups, plus sleep and mood support. Delivered alongside the GP and, where needed, a psychologist or rheumatologist.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. One trial, pressure pain only
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling (the same technique with nothing injected) is not offered here.
What the evidence shows
Evidence is limited. One sham-controlled randomised trial of dry needling in fibromyalgia reported benefit on pressure pain threshold only, in the short term (Vicente-Mampel, 2024). A single trial with a narrow outcome does not establish an effect on pain or function.
Pairing reviewed 2026-10-11.
Where it fits
A short-term option to discuss for a tender regional band, with the weak evidence stated. It does not replace exercise or sleep and mood care.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. Plausible: no studies
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis, and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
A PubMed search of fibromyalgia with injection terms found no trial of image-guided local injection as treatment for fibromyalgia. The nearest is a single-centre, single-blind sham-controlled trial of stellate ganglion block in 68 people on stable duloxetine, which reported FIQR 29.9 points better than sham at one week and 22.9 at one month, with the authors cautioning that unblinding and placebo effects may explain part of it (Dadakci, Pain Res Manag 2026).
Pairing reviewed 2026-10-11.
Where it fits
Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Plausible: no studies
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
A PubMed search pairing fibromyalgia with vibration or percussive devices found no trial of handheld percussive devices in fibromyalgia.
Pairing reviewed 2026-10-11.
Where it fits
Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. One trial, mostly no difference
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue, including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
The one sham-controlled randomised trial of radial shockwave in fibromyalgia found no statistically significant between-group differences on most measures, though visual analogue scale changes in the shockwave group reached the minimal clinically important difference, and it was reported as safe (Sanzo, Physiother Theory Pract 2024). A 2022 scoping review of 19 studies found benefit in localised myofascial pain but no evidence in fibromyalgia (Paoletta). A 2023 meta-analysis of 27 trials found shockwave beat control in myofascial pain syndrome but no better than dry needling, exercise or injections (Avendano-Lopez, Am J Phys Med Rehabil 2024). Myofascial pain is a regional condition, not fibromyalgia.
Pairing reviewed 2026-10-11.
Where it fits
Only for a separate localised myofascial or tendon problem found on examination, not as treatment for fibromyalgia, with the single negative-leaning trial stated.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. Plausible: no studies
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form used for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
A PubMed search of fibromyalgia with shockwave terms found one randomised trial, of radial shockwave (see that row), and none of focused shockwave.
Pairing reviewed 2026-10-11.
Where it fits
Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. Low quality, short term
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given as a course, commonly alongside shockwave.
What the evidence shows
Evidence is low quality. A 2025 meta-analysis of six sham-controlled randomised trials of peripheral magnetic stimulation found low-quality evidence of short-term benefit, with long-term effects unknown (Leenus, 2025). For pulsed electromagnetic fields only a three-patient case series combined with ozone therapy was found (Lara-Reyes, 2026).
Pairing reviewed 2026-10-11.
Where it fits
Offered only as an adjunct once exercise, education and sleep and mood care are under way, with the low-quality, short-term evidence explained first. Much of the device literature is manufacturer-linked.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Plausible: no studies
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
A PubMed search pairing fibromyalgia with platelet-rich plasma found no trial.
Pairing reviewed 2026-10-11.
Where it fits
Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Plausible: no studies
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
A PubMed search pairing fibromyalgia with prolotherapy or dextrose found no trial.
Pairing reviewed 2026-10-11.
Where it fits
Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Not offered for this
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
Hyaluronic acid is for intra-articular problems. Fibromyalgia is a widespread pain condition, not a joint problem, and no trial of hyaluronic acid in it was found.
Pairing reviewed 2026-10-11.
Where it fits
Not offered for fibromyalgia.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve, not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Plausible: no studies
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
A PubMed search pairing fibromyalgia with perineural injection or nerve block found no trial beyond the stellate ganglion block trial described under guided injection.
Pairing reviewed 2026-10-11.
Where it fits
Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Plausible: no studies
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
A PubMed search pairing fibromyalgia with hydrodissection found no trial.
Pairing reviewed 2026-10-11.
Where it fits
Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal: a trip, a procedure, a return to work
- Diagnostic use, where the response shows where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other general conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Frequently asked questions
Is there a test for fibromyalgia?
What actually helps?
Do injections, shockwave or needling treat fibromyalgia?
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