Fibromyalgia, a disease of chronic widespread pain, fatigue, poor sleep, stiffness and many other symptoms, is associated with considerable disability and is estimated to affect 3.4% of the population. Optimal management of fibromyalgia is still in question, but exercise is recommended as one component of multidisciplinary management programs. In this review, we examine the effects of land-based and aquatic aerobic, strength and mixed exercise, as well as composite programs including exercise, on five important outcome constructs (global well-being, pain, tender points, physical function and depression). We detail adverse effects, attrition rates and adherence to exercise, as well as identify methodological problems in the published research. We provide evidence-based recommendations for exercise/physical activity for improvement of fibromyalgia symptoms and physical function and explore the importance and clinical implications of moving towards the application of the 2007 physical activity guidelines developed by the American College of Sports Medicine and the American Heart Association for individuals with fibromyalgia.