Barriers and facilitators to exercise in fibromyalgia: a theory-informed qualitative study of behavioral determinants

Background Exercise is recommended for fibromyalgia, yet engagement remains difficult and appears to be shaped by more than symptoms alone. Objective To explore how individuals with fibromyalgia experience exercise and to interpret these accounts through the Capability, Opportunity, Motivation–Behavior (COM-B) model and the Theoretical Domains Framework (TDF), in order to identify behavioral determinants relevant to intervention design. Methods Adults diagnosed with fibromyalgia according to the 2016 criteria were purposively involved in Italy. Semi-structured interviews were conducted via video call using a COM-B-informed guide, audio-recorded, and transcribed verbatim. Data were analyzed using reflexive thematic analysis, with themes generated primarily inductively and subsequently mapped deductively onto TDF domains. Results Fourteen participants completed the interviews (13 women; 92.9%; mean age 48.1 ± 11.6 years; mean interview duration 31.1 ± 7.2 min). Four interpretive themes were generated: exercise as a negotiated balance between necessity and threat; living with uncertainty through fear, ambivalence, and emotional regulation; wanting autonomy but needing guidance; and exercise support as enabling when individualized but discouraging when poorly matched to symptoms and abilities. Exercise was continuously weighed in terms of anticipated benefit versus anticipated harm. Fear of symptom exacerbation, uncertainty about exercise dosing, and low confidence in self-management often limited engagement, whereas gradual tailoring, credible guidance, supportive relationships, and appropriate environments promoted participation. Conclusion Barriers and facilitators to exercise in fibromyalgia emerge from a dynamic behavioral process shaped by interacting capability, opportunity, and motivation factors. Exercise support may be more acceptable when it is individualized, psychologically informed, and context sensitive.