Effectiveness of Aerobic Exercise in Fibromyalgia: A Systematic Review and Network Meta-analysis

Fibromyalgia is a chronic syndrome characterized by widespread musculoskeletal pain, fatigue, depressive symptoms, and sleep disturbances, with substantial impairment in quality of life. Aerobic exercise is widely recommended as a non-pharmacological management strategy, and evidence supports benefits for both physical and psychological outcomes. However, comparative evidence on different exercise modalities remains limited. This study aimed to compare the effects of various exercise interventions on overall health status, pain intensity, depressive symptoms, and sleep quality in patients with fibromyalgia using a network meta-analysis (NMA). PubMed, Embase, the Cochrane Library, and Web of Science were systematically searched from inception to February 7, 2025, for randomized controlled trials (RCTs). An NMA was conducted to compare Baduanjin, dance, Pilates, swimming, Tai Chi, walking, yoga, and Liuzijue in patients with fibromyalgia. Effect sizes were estimated using random-effects models, and risk of bias was independently assessed using the Cochrane Risk of Bias tool. Statistical analyses were performed using Stata 15.0 and R 4.4.0. Twenty randomized controlled trials involving 1,196 patients with fibromyalgia and eight aerobic exercise interventions were included. In relative-effect comparisons versus control, swimming showed the greatest improvement in overall health status (MD = -23.36; 95% CI [-40.77, -4.32]). Liuzijue showed the greatest benefit for pain intensity (MD = -3.69; 95% CI [-5.37, -2.02]) and was also most likely to improve sleep quality (MD = -5.29; 95% CI [-8.98, -1.64]). For depressive symptoms, walking had the highest treatment-ranking probability; however, its estimated effect versus control was not statistically significant (MD = -5.99; 95% CI [-14.67, 2.74]). Among single-form aerobic exercise interventions for fibromyalgia, swimming appeared to provide the greatest improvement in overall health status, while Liuzijue showed favorable effects on pain reduction and sleep quality. Walking ranked highest for depressive symptoms, but the evidence for its effect was uncertain. These findings support consideration of selected aerobic exercise modalities as complementary non-pharmacological options in fibromyalgia management, while further high-quality RCTs are needed to strengthen the evidence. • A network meta-analysis compared eight aerobic exercise modalities for fibromyalgia. • Twenty RCTs (n = 1,196) were included, assessing health status, pain, depression, and sleep. • Swimming showed the greatest improvement in overall health status versus control. • Liuzijue provided the largest pain reduction and was most likely to improve sleep quality. • Walking ranked highest for depressive symptoms, but the effect versus control was uncertain.