In this group (mindfulness-based stress reduction) participants will take part in 9 group sessions.

The groups sessions will be divided into 8 weekly 2-hour groups sessions and one 6-hour "retreat". During the sessions participants will practice mindfulness exercises directed by the a MBSR therapist. Additionally, participants will also be asked to practice daily formal mindfulness at home using audio recordings of 30-45 minute guided meditation exercises. These audio recordings can be accessed online. The sessions may take place in-person or virtually.

Participants will take part in 10 physical therapy visits over the course of 8 weeks. Participants will meet with the physical therapist twice a week for a 1-hour session for weeks 1 and 2 and then weekly for the remaining 6 weeks. The physical therapist will tailor a program to the participant's needs according to recommended PT practice guidelines that will include in-person treatment, home exercise prescription, and encouragement of progressive, low-intensity, submaximal fitness and endurance activities, such as walking.

Participants will be given a home program of exercises to be done daily and asked to engage in daily walking with a set goal based on the individual's capacity and current fitness level. Walking was selected as the aerobic exercise of focus for this treatment because it is recommended for patients with all levels of pain severity, is highly feasible to complete, and has shown effects on outcomes such as pain and disability.

A device called the "AcuWand" will be used to administer the self-acupressure intervention for approximately 30 minutes daily for 8 weeks. Participants will use a mobile application (app) called "MeTime" that will have daily instructions on how to use the AcuWand. Research staff will show participants how to use the AcuWand and MeTime app. In addition, participants will keep a daily log to track at-home acupressure sessions.

For days 1-7, patients will take 30mg of duloxetine once a day, in the morning. Starting day 8, participants tolerating the medication will be escalated to 60mg once a day. They will also have the option of staying at 30mg, once a day or stopping the medication. At the end of the 8-week intervention period, participants will have the option to continue the medication commercially (non-study medication) under the care of their physician or taper off the medication. During the entire 8-week intervention, patients will be asked to keep a daily log of medication dosage, any missed doses, and any side-effects they may have experienced.

Participants will wear during 5 separate 7-day "home monitoring" periods to assess physical activity (objectively measured via accelerometry), and ecological momentary assessment (EMA) of mental and physical symptoms. EMA will be collected during Weeks 1, 6, 15, 24 and 36.

Participants who attended T2 visit.

Of those who attended T2 visit, participants who attended T3.

Participants who attended T3 visit.

Of note, there are participants that missed T2 but attended T3. This accounts for the difference in participants that completed T3/Period 2 and those that started T3/Period 3.

Of those who attended T3 visit, participants who attended T4.

Participants who attended T4 visit.

Of note, there are participants that missed T3 but attended T4. This accounts for the difference in participants that completed T4/Period 3 and those that started T4/Period 4.

Participants who attended T5 and final study visit.

PT and exercise: Participants will take part in 10 physical therapy visits over the course of 8 weeks. Participants will meet with the physical therapist twice a week for a 1-hour session for weeks 1 and 2 and then weekly for the remaining 6 weeks. The physical therapist will tailor a program to the participant's needs according to recommended PT practice guidelines that will include in-person treatment, home exercise prescription, and encouragement of progressive, low-intensity, submaximal fitness and endurance activities, such as walking.

Participants will be given a home program of exercises to be done daily and asked to engage in daily walking with a set goal based on the individual's capacity and current fitness level. Walking was selected as the aerobic exercise of focus for this treatment because it is recommended for patients with all levels of pain severity, is highly feasible to complete, and has shown effects on outcomes such as pain and disability.

Pro-Diary monitor: Participants will wear during 5 separate 7-day "home monitoring" periods to assess physical activity (objectively measured via accelerometry), and ecological momentary assessment (EMA) of mental and physical symptoms. EMA will be collected during Weeks 1, 6, 15, 24 and 36.

MBSR: In this group (mindfulness-based stress reduction) participants will take part in 9 group sessions.

The groups sessions will be divided into 8 weekly 2-hour groups sessions and one 6-hour "retreat". During the sessions participants will practice mindfulness exercises directed by the a MBSR therapist. Additionally, participants will also be asked to practice daily formal mindfulness at home using audio recordings of 30-45 minute guided meditation exercises. These audio recordings can be accessed online. The sessions may take place in-person or virtually.

Pro-Diary monitor: Participants will wear during 5 separate 7-day "home monitoring" periods to assess physical activity (objectively measured via accelerometry), and ecological momentary assessment (EMA) of mental and physical symptoms. EMA will be collected during Weeks 1, 6, 15, 24 and 36.

Duloxetine: For days 1-7, patients will take 30mg of duloxetine once a day, in the morning. Starting day 8, participants tolerating the medication will be escalated to 60mg once a day. They will also have the option of staying at 30mg, once a day or stopping the medication. At the end of the 8-week intervention period, participants will have the option to continue the medication commercially (non-study medication) under the care of their physician or taper off the medication. During the entire 8-week intervention, patients will be asked to keep a daily log of medication dosage, any missed doses, and any side-effects they may have experienced.

Pro-Diary monitor: Participants will wear during 5 separate 7-day "home monitoring" periods to assess physical activity (objectively measured via accelerometry), and ecological momentary assessment (EMA) of mental and physical symptoms. EMA will be collected during Weeks 1, 6, 15, 24 and 36.

Total of all reporting groups

Collected through Qualtrics administered survey

Pain duration was unknown on 3 participants in the Acupressure arm and 1 participant in the PT arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The PROMIS pain interference consists of 4 questions on a Likert scale ranging from 'Not at all" (1) to "Very much" (5). Total scores are between 4 and 20, with higher scores indicating increased pain interference.

Pain Interference was unknown on 3 participants in the Acupressure arm, 1 participant in the PT arm, 1 participant in the MBSR arm, and 1 participant in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

This is a 3 question scale where participants select a between 0 (no pain) to 10 (pain is bad and completely interferes). Higher the scores the worse the pain.

PEG was unknown on 3 participants in the Acupressure arm, 1 participant in the PT arm, 1 participant in the MBSR arm, and 1 participant in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The PROMIS physical function consists of 3 questions on a Likert scale ranging from 'Unable to Do" (1) to "Without any difficulty" (5) and 2 questions on a Likert scale ranging from "Cannot Do" to "Not at all". Total scores are between 6 and 30, with higher scores indicating increased physical function.

PROMIS Physical Function was unknown on 3 participants in the Acupressure arm, 1 participant in the PT arm, 1 participant in the MBSR arm, and 2 participant in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The PROMIS sleep disturbance consists of 5 questions on a Likert scale ranging from 'Not at all" (1) to "Very much" (5) and 1 question on a Likert scale ranging from 'Very good' (1) to 'Very poor' (5). Total scores are between 6 and 30, with higher scores indicating increased sleep disturbance.

PROMIS Sleep Disturbance was unknown on 3 participants in the Acupressure arm, 2 participant in the PT arm, 1 participant in the MBSR arm, and 1 participant in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The PROMIS depression consists of 4 questions on a Likert scale ranging from 'Never' (1) to 'Always' (5). Total scores are between 4 and 20, with higher scores indicating increased depression.

PROMIS Depression was unknown on 4 participants in the Acupressure arm, 1 participant in the PT arm, 1 participant in the MBSR arm, and 2 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The PROMIS anxiety consists of 4 questions on a Likert scale ranging from 'Never' (1) to "Always" (5). Total scores are between 4 and 20, with higher scores indicating increased anxiety.

PROMIS Anxiety was unknown on 4 participants in the Acupressure arm, 1 participant in the PT arm, 1 participant in the MBSR arm, and 2 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The PROMIS fatigue consists of 4 questions on a Likert scale ranging from 'Not at all" (1) to "Very much" (5). Total scores are between 4 and 20, with higher scores indicating increased fatigue.

PROMIS Fatigue was unknown on 4 participants in the Acupressure arm, 1 participant in the PT arm, 3 participants in the MBSR arm, and 2 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The PROMIS Social Roles and Activities consists of 4 questions on a Likert scale ranging from 'Always" (1) to "Never" (5). Total scores are between 4 and 20, with higher scores indicating increased ability to participate in social activities.

Pain Interference was unknown on 4 participants in the Acupressure arm, 1 participant in the PT arm, 3 participants in the MBSR arm, and 2 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The PROMIS cognitive function consists of 2 questions on a Likert scale ranging from 'Not at all" (1) to "Very much" (5). Total scores are between 2 and 10, with higher scores indicating increased cognitive function.

PROMIS Cognitive Function was unknown on 4 participants in the Acupressure arm, 1 participant in the PT arm, 4 participants in the MBSR arm, and 2 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The PROMIS pain intensity consists of 1 question on a Likert scale ranging from 'No Pain" (0) to "Worst Imaginable Pain" (10). Total scores are between 0 and 10, with higher scores indicating increased pain intensity.

PROMIS Pain Intensity was unknown on 3 participants in the Acupressure arm, 1 participant in the PT arm, 3 participants in the MBSR arm, and 2 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The Michigan Body Map is assessed electronically and assesses number of regions the study participant has pain, 0 (No Chronic Pain) - 36 (All Pain Regions).

The Michigan Body Map was unknown on 4 participants in the Acupressure arm, 1 participant in the PT arm, 2 participants in the MBSR arm, and 2 participants in the duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

Participants meeting the 2016 Fibromyalgia Criteria.

1. Widespread pain index (WPI) and symptom severity score (SSS)

   WPI ≥ 7 and SSS ≥ 5 OR WPI 4-6 and SSS ≥ 9

2. Generalized pain: pain in 4/5 regions

3. Symptoms present ≥ 3 months

2016 Fibromyalgia Criteria was unknown on 4 participants in the Acupressure arm, 1 participant in the PT arm, 3 participants in the MBSR arm, and 2 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The PainDetect measure consists of 14 questions - 7 questions on a Likert scale ranging from 'Never" (0) to "Very strongly" (5), 2 body region questions, 1 y/n question assessing pain, 1 visual question assessing type of back pain, and 3 questions on a Likert scale ranging from "none" (0) to "Max" (10). Higher scores indicating increase back pain in more regions.

PainDetect was unknown on 4 participants in the Acupressure arm, 5 participants in the PT arm, 5 participants in the MBSR arm, and 6 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

GSS-8 measures sensitivity with 8 questions in a yes/no format. Scores range from 0 to 8 with higher scores indicating increased sensitivity.

The Pain Catastrophizing Questionnaire consists of 13 questions on a Likert scale ranging from 'Not at all" (0) to "All the time" (4). Total scores are between 0 and 52, with higher scores indicating increased catastrophizing.

Pain Catastrophizing Scale (PCS) was unknown on 4 participants in the Acupressure arm, 1 participant in the PT arm, 1 participant in the MBSR arm, and 1 participant in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The Pain Self Efficacy Quesionnaire (PSEQ) consists of 10 questions on a Likert scale ranging from 'Not at all confident" (0) to "Completely Confident" (6). Total scores are between 0 and 60, with higher scores indicating increased self efficacy.

Pain Self Efficacy Questionnaire (PSEQ) was unknown on 4 participants in the Acupressure arm, 2 participants in the PT arm, 3 participants in the MBSR arm, and 2 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The Fear Avoidance Belief Questionnaire consists of 16 questions on a Likert scale ranging from 'Completely Disagree" (0) to "Completely Agree" (6). Total scores are between 0 and 96, with higher scores indicating fear avoidance.

Fear Avoidance Belief Questionnaire (FABQ) was unknown on 4 participants in the Acupressure arm, 2 participants in the PT arm, 5 participants in the MBSR arm, and 3 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The Chronic Pain Acceptance Questionnaire consists of 8 questions on a Likert scale ranging from 'Never" (0) to "Always true" (6). Total scores are between 0 and 48, with higher scores indicating increased pain acceptance.

Chronic Pain Acceptance Questionnaire (CPAQ) was unknown on 4 participants in the Acupressure arm, 2 participants in the PT arm, 6 participants in the MBSR arm, and 2 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The Experiences Questionnaire (EQ-11) consists of 11 questions on a Likert scale ranging from 'Never' (1) to 'All the time' (5). Total scores are between 11 and 55. A higher total score indicates a greater ability to decenter, which is a positive indicator of detached observation of one's internal experiences.

Experiences Questionnaire was unknown on 5 participants in the Acupressure arm, 2 participants in the PT arm, 6 participants in the MBSR arm, and 4 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The Perceived Stress Scale consists of 10 questions on a Likert scale ranging from 'Never' (0) to 'Very often' (4). Total scores are between 0 and 40, with higher scores indicating increased perceived stress.

Perceived Stress Scale was unknown on 4 participants in the Acupressure arm, 2 participants in the PT arm, 2 participants in the MBSR arm, and 3 participants in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

The Positive and Negative Affect Schedule (PANAS) is a 20-item self-report measure that assesses two distinct dimensions of mood: positive affect and negative affect. Participants rate the extent to which they have experienced each emotion over a specified time frame using a 5-point Likert scale - "Very slightly or not at all" (1) to "Extremely" (5). The PANAS score is separated into two subscales of Positive Affect (PA) and Negative Affect (NA), with a higher score indicating more positive or negative affect respectively. Each subscale ranges from 10-50.

Positive and Negative Affect Scale (PANAS) was unknown on 4 participants in the Acupressure arm, 2 participants in the PT arm, 5 participants in the MBSR arm, and 4/5 (positive/negative) participant in the Duloxetine arm. This question was not required, so patients could choose not to answer. This is reflected in the number analyzed category.

PT and exercise: Participants will take part in 10 physical therapy visits over the course of 8 weeks. Participants will meet with the physical therapist twice a week for a 1-hour session for weeks 1 and 2 and then weekly for the remaining 6 weeks. The physical therapist will tailor a program to the participant's needs according to recommended PT practice guidelines that will include in-person treatment, home exercise prescription, and encouragement of progressive, low-intensity, submaximal fitness and endurance activities, such as walking.

Participants will be given a home program of exercises to be done daily and asked to engage in daily walking with a set goal based on the individual's capacity and current fitness level. Walking was selected as the aerobic exercise of focus for this treatment because it is recommended for patients with all levels of pain severity, is highly feasible to complete, and has shown effects on outcomes such as pain and disability.

Pro-Diary monitor: Participants will wear during 5 separate 7-day "home monitoring" periods to assess physical activity (objectively measured via accelerometry), and ecological momentary assessment (EMA) of mental and physical symptoms. EMA will be collected during Weeks 1, 6, 15, 24 and 36.

Self -administered acupressure: A device called the "AcuWand" will be used to administer the self-acupressure intervention for approximately 30 minutes daily for 8 weeks. Participants will use a mobile application (app) called "MeTime" that will have daily instructions on how to use the AcuWand. Research staff will show participants how to use the AcuWand and MeTime app. In addition, participants will keep a daily log to track at-home acupressure sessions.

Pro-Diary monitor: Participants will wear during 5 separate 7-day "home monitoring" periods to assess physical activity (objectively measured via accelerometry), and ecological momentary assessment (EMA) of mental and physical symptoms. EMA will be collected during Weeks 1, 6, 15, 24 and 36.

Duloxetine: For days 1-7, patients will take 30mg of duloxetine once a day, in the morning. Starting day 8, participants tolerating the medication will be escalated to 60mg once a day. They will also have the option of staying at 30mg, once a day or stopping the medication. At the end of the 8-week intervention period, participants will have the option to continue the medication commercially (non-study medication) under the care of their physician or taper off the medication. During the entire 8-week intervention, patients will be asked to keep a daily log of medication dosage, any missed doses, and any side-effects they may have experienced.

Pro-Diary monitor: Participants will wear during 5 separate 7-day "home monitoring" periods to assess physical activity (objectively measured via accelerometry), and ecological momentary assessment (EMA) of mental and physical symptoms. EMA will be collected during Weeks 1, 6, 15, 24 and 36.

This is a 3 question scale where participants select a between 0 (no pain) to 10 (pain is bad and completely interferes). Higher the scores the worse the pain.

Of the 402 randomized participants, 331 who completed T3 study visit were analyzed. Participants excluded from this analysis are those who did not complete either T2 or T3.

This is a 1 question item where participants described their perceived improvement between T2 and T3 by selecting a score between 1 and 7, where 1 indicated "very much improved" and 7 indicated "very much worse. The lower the score, the greater improvement in perceived pain.

Data is presented as count of participants who scored their improvement as a 1 or a 2 and those who scored their improvement as 3 or higher.

Of the 402 randomized participants, 331 who completed T3 study visit were analyzed. Participants excluded from this analysis are those who did not complete either T2 or T3.

PT and exercise: Participants will take part in 10 physical therapy visits over the course of 8 weeks. Participants will meet with the physical therapist twice a week for a 1-hour session for weeks 1 and 2 and then weekly for the remaining 6 weeks. The physical therapist will tailor a program to the participant's needs according to recommended PT practice guidelines that will include in-person treatment, home exercise prescription, and encouragement of progressive, low-intensity, submaximal fitness and endurance activities, such as walking.

Participants will be given a home program of exercises to be done daily and asked to engage in daily walking with a set goal based on the individual's capacity and current fitness level. Walking was selected as the aerobic exercise of focus for this treatment because it is recommended for patients with all levels of pain severity, is highly feasible to complete, and has shown effects on outcomes such as pain and disability.

Pro-Diary monitor: Participants will wear during 5 separate 7-day "home monitoring" periods to assess physical activity (objectively measured via accelerometry), and ecological momentary assessment (EMA) of mental and physical symptoms. EMA will be collected during Weeks 1, 6, 15, 24 and 36.

Self -administered acupressure: A device called the "AcuWand" will be used to administer the self-acupressure intervention for approximately 30 minutes daily for 8 weeks. Participants will use a mobile application (app) called "MeTime" that will have daily instructions on how to use the AcuWand. Research staff will show participants how to use the AcuWand and MeTime app. In addition, participants will keep a daily log to track at-home acupressure sessions.

Pro-Diary monitor: Participants will wear during 5 separate 7-day "home monitoring" periods to assess physical activity (objectively measured via accelerometry), and ecological momentary assessment (EMA) of mental and physical symptoms. EMA will be collected during Weeks 1, 6, 15, 24 and 36.

Duloxetine: For days 1-7, patients will take 30mg of duloxetine once a day, in the morning. Starting day 8, participants tolerating the medication will be escalated to 60mg once a day. They will also have the option of staying at 30mg, once a day or stopping the medication. At the end of the 8-week intervention period, participants will have the option to continue the medication commercially (non-study medication) under the care of their physician or taper off the medication. During the entire 8-week intervention, patients will be asked to keep a daily log of medication dosage, any missed doses, and any side-effects they may have experienced.

Pro-Diary monitor: Participants will wear during 5 separate 7-day "home monitoring" periods to assess physical activity (objectively measured via accelerometry), and ecological momentary assessment (EMA) of mental and physical symptoms. EMA will be collected during Weeks 1, 6, 15, 24 and 36.

5 week period leading up to randomization at T2 visit during which participants had access to the PainGuide self-managment program.

Participants who were on follow-up due to PGIC=1 at T2 or T3, the week between treatment 1 and 2 or post treatment 2.