Table 2.

Evidence-based framework for fibromyalgia online interventions.

Intervention domain	Evidence level and rationale	Implementation in mobile health app	Digital enablement features	Evaluation metrics
Psychoeducational therapies (CBTa, ACTb, and PNEc)	Strong evidence from RCTsd and guidelines for reducing pain, distress, and maladaptive thoughts	Modular courses; microlearning sessions; quizzes; journaling; goal setting; and self-efficacy tracking	Chatbots or avatars for guidance; adaptive progression based on symptom and mood data; empathy-based conversational tone; and voice message transcription	Pain, FIQe, self-efficacy, catastrophizing, engagement rate, and module completion
Physical activity and graded exercise	Strong evidence for aerobic and resistance training improving function and mood	Video demonstrations; personalized exercise plans; daily movement reminders; wearable integration (steps, HRf, and HRVg)	AIh-driven motion feedback (computer vision); adaptive load progression; safety alerts; and gamification	Physical function (FIQ physical domain), fatigue, adherence (logged sessions), and HR and HRV trends
Mind-body techniques (mindfulness, Tai Chi, breathing, and relaxation)	Moderate evidence for improving sleep, mood, and QoLi	Audio-guided meditations, breathing animations, mindfulness timers, and relaxation music	Adaptive session lengths; stress biofeedback using HRV; sleep tracking linkage; and integration with smartwatches	Sleep quality, stress index, anxiety, HRV, and app usage continuity
Symptom tracking and patient-reported outcomes	Essential for personalization and clinical insight for HCPj	In-app FIQ, pain diaries, and fatigue and sleep trackers	Voice or video symptom entry; AI-based summary visualization; and adaptive dashboard	Data completeness, trend accuracy, and correlation with clinical outcomes
Personalization and adaptive design	Increasingly essential for engagement and relevance	Custom goal setting; phenotype-based pathways (eg, obesity-, menopause-, and PTSDk-related FMl)	Machine learning–based tailoring; predictive suggestions for pacing and exercise. Adapted avatars, eg, older people with obesity	User satisfaction, engagement over time, and adaptive accuracy
Behavior change and motivation	Crucial for long-term adherence	SMARTm goal planning, feedback loops, and progress visualization	Gamification, motivational messaging, positive reinforcement, and social comparison (optional)	Retention rate, adherence index, and self-efficacy gain
Communication and support	Improves adherence and patient safety	Chatbot or professional chat; asynchronous therapist feedback	Hybrid care integration (eg, AI triage + human follow-up); crisis escalation paths	Message frequency, satisfaction, and safety events
Data integration and clinical workflow	Enables clinical supervision and research	Clinician dashboard, FHIRn-based interoperability, and data export to EHRo	Sidecar EMR integration; secure teleconsultation channel	Clinical uptake, data completeness, and clinician feedback
Accessibility, UXp, and emotional design	Critical for usability and adherence in cognitive fatigue	Clean interface, large icons, voice navigation, and light and dark modes	Emotionally supportive design (colors, feedback tone), simplified onboarding, and language localization	SUSq score, accessibility compliance, and dropout rate
Privacy, certification, and ethics	Required for trust and scalability	CEr, FDAs, or DiGAt conformity, and transparent data policies	Privacy-by-design architecture; on-device data processing	Certification status, GDPRu or HIPAAv compliance, and user trust rating

^aCBT: cognitive behavioral therapy.

^bACT: acceptance and commitment therapy.

^cPNE: pain neuroscience education.

^dRCT: randomized controlled trial.

^eFIQ: Fibromyalgia Impact Questionnaire.

^fHR: heart rate.

^gHRV: heart rate variability.

^hAI: artificial intelligence.

ⁱQoL: quality of life.

^jHCP: health care professional.

^kPTSD: posttraumatic stress disorder.

^lFM: fibromyalgia.

^mSMART: specific, measurable, achievable, relevant, time-bound.

ⁿFHIR: Fast Healthcare Interoperability Resources.

^oEHR: electronic health record.

^pUX: user experience.

^qSUS: System Usability Scale.

^rCE: Conformité Européenne.

^sFDA: US Food and Drug Administration.

^tDiGA: Digitale Gesundheitsanwendung.

^uGDPR: General Data Protection Regulation.

^vHIPAA: Health Insurance Portability and Accountability Act.