Fibromyalgia treatment often involves a combination of approaches, and the choice between exercise or cognitive behavioral therapy (CBT) first depends on the patient’s specific symptoms, preferences, and medical guidance. Both are evidence-based options, but here’s a breakdown based on current understanding:

• Exercise: Often recommended as a first-line treatment because it can reduce pain, improve physical function, and boost mood. Low-impact aerobic exercise (e.g., walking, swimming) and strength training, tailored to the patient’s tolerance, are effective. Starting slowly and gradually increasing intensity is key to avoid symptom flares. Studies, like those summarized in a 2023 review, show exercise can significantly reduce fibromyalgia pain and fatigue, with benefits seen in 6–12 weeks of consistent activity.
• CBT: Focuses on managing pain perception, stress, and negative thought patterns, which can amplify fibromyalgia symptoms. It’s particularly helpful for patients with significant psychological distress, anxiety, or depression. CBT can improve coping strategies and quality of life, with some trials showing reduced pain intensity after 8–12 weeks of therapy.

Which to start with?

• If physical symptoms (pain, fatigue) are the primary concern and the patient is able, starting with a gentle exercise program under professional guidance (e.g., physical therapist) is often prioritized, as it directly addresses physical limitations and has broader health benefits.
• If mental health challenges (e.g., anxiety, depression) or poor pain coping dominate, CBT may be the better starting point to build resilience and motivation for other treatments, including exercise.
• In practice, many clinicians recommend integrating both early on, as they complement each other. For example, exercise can enhance mood, while CBT can improve adherence to exercise by addressing fear of pain or movement.

Key considerations:

• Always consult a healthcare provider to tailor the approach. Comorbidities (e.g., severe depression, joint issues) or patient readiness can influence the starting point.
• Neither is a cure; they’re part of a broader management plan, often including medication, sleep hygiene, or stress reduction.