Network meta-analysis ranks exercise modalities for fibromyalgia impact in women

BACKGROUND: Therapeutic exercise is the only intervention with strong evidence for fibromyalgia, yet the most effective modality remains uncertain. OBJECTIVE: To determine which modality of therapeutic exercise is the most effective in reducing the impact of fibromyalgia in women, as assessed by the Fibromyalgia Impact Questionnaire (FIQ/FIQR). DESIGN: Systematic review with a network meta-analysis of randomized controlled trials. METHODS: A comprehensive search was performed in MEDLINE, Cochrane Library, Scopus, Web of Science, and CINAHL from inception to March 2025. Eligible randomized controlled trials involved therapeutic exercise interventions reporting Fibromyalgia Impact Questionnaire outcomes. Data synthesis followed PRISMA-NMA guidelines, using a frequentist network meta-analysis to estimate effect sizes and clinically important differences in the short term (≤3 months) and long term (>3 months). Certainty of evidence was assessed with CINeMA. RESULTS: Sixty-four studies were identified, of which 59 were included in the quantitative synthesis (n = 3256). Fourteen modalities of therapeutic exercise and seven comparison interventions (comparators) were identified. In the short term, Pilates, Aquatic Exercise, and Resistance Exercise ranked highest. In the long term, Dance and Mixed Exercise ranked highest. Certainty of evidence was mostly low to moderate (CINeMA), mainly limited by imprecision and heterogeneity. CONCLUSIONS: Pilates, Aquatic Exercise, and Resistance Exercise ranked highest in the short term, while Dance and Mixed Exercise ranked highest in the long term. However, findings should be interpreted with caution due to substantial heterogeneity and mostly low-to-moderate certainty of evidence.