Familial Mediterranean Fever (FMF)

Episodes last one to three days and resolve completely 2. Between attacks most patients feel well. The pain during an abdominal attack is severe enough that many patients have had an unnecessary appendicectomy before the diagnosis was made.

Joint involvement is usually a single large joint, most often the knee or ankle, and it settles without damage. A small number develop prolonged arthritis in one joint that does not settle for weeks.

Continuous colchicine prevents attacks in most patients and, more importantly, prevents AA amyloidosis. Stopping it because attacks have stopped is the common and dangerous error — the drug is what is stopping them.

We state this plainly because patients travelling for rehabilitation sometimes arrive having paused their medication, and no rehabilitation programme substitutes for it.

Restoring strength and range in a knee or ankle after a prolonged attack of arthritis; managing chronic musculoskeletal pain where it has developed; and reconditioning after a period of reduced activity. Exercise capacity between attacks is often lower than people assume: adults in remission walked a shorter distance in six minutes and had weaker hip and ankle muscles than healthy peers 3.

Where amyloidosis has affected the kidney, exercise is planned with the nephrology team and the programme is built around what renal function and blood pressure allow.

The attacks themselves are managed medically, and colchicine both controls them and prevents amyloidosis, which is the complication that determines long-term outcome.

What rehabilitation addresses is what accumulates between attacks: joint range after arthritis, deconditioning from repeated episodes, and chronic pain where it has developed.

Pain in the legs after physical effort or prolonged standing is a recognised feature of FMF, not simply a sign of being unfit 3. It affected 36% of 1,290 children in one clinic series, where it went with more severe disease 4. In a series of 135 adults it affected 48% and went with more active disease 5.

It often persists despite colchicine; in a small study of people whose disease did not respond to colchicine, interleukin-1 blocking drugs improved it in about half 6. New or worsening leg pain with activity is therefore worth reporting to the rheumatologist rather than training through it.

Many people with FMF believe so. In a survey of 882 adults, the triggers named most often were psychological stress (75.2%) and fatigue (63.6%), followed by seasonal changes and cold exposure, and 51.0% of women reported more frequent or severe attacks around menstruation 7. These are recalled associations, not proven causes 7.

For training, that argues for steady progression rather than exhausting sessions, and for keeping warm during pool and outdoor work. A session is better moved than pushed through when an attack is starting. None of this replaces colchicine, which reduces attacks and prevents amyloidosis 2.