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RELATION OF DURATION OF BED REST IN ACUTE RHEUMATIC FEVER TO HEART DISEASE PRESENT 2 TO 14 YEARS LATER

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RELATION

OF

DURATION

OF

BED

REST

IN

ACUTE

RHEUMATIC

FEVER

TO

HEART

DISEASE

PRESENT

2 TO

14 YEARS

LATER

By Bessie 1. Lendrum, M.D., Albert J. Simon, M.D., and Irving Mack, M.D.

Herrick House, Bartlett, illinois

(Accepted March 30, 1959; submitted January 27.)

This study was supported by a grant from the Chicago Heart Association.

PRESENT ADDRESS: (B.L.L.) Department of Pediatrics, State University of New York, Upstate Medical

Center, 766 Irving Avenue, Syracuse 10, New York.

389

Pxrwriucs, September 1959

T

HE MEDICAL management of children

witil acute rheumatic fever has

under-gone remarkable changes in the past

dee-ade. It is no longer considered “radical

management” to mobilize a patient

promptly upon disappearance of the acute

signs and symptoms of rheumatic activity instead of imposing prolonged periods of

bed rest. A few investigators have recently

advocated permitting ambulation and

phy-sical activity to tolerance within the first few days after the onset of the acute

at-tack even in the presence of 2

There are very few data available in the

literature, however, to support the clinical

impression that prolonged bed rest is not

necessary to secure optimal myocardial

healing. For this reason it seems desirable

to record clinical studies designed to test

the validity of this impression.

In 1946 when Herrick House was

con-verted from a summer residence for

chil-dren convalescing from rheumatic fever to

a year-round convalescent home, it became

one of the first institutions to abandon

pro-longed bed rest. Detailed description of

the Herrick House program has been

pub-lished previously. : A long-term study was

undertaken by the medical staff at that time to determine whether abandonment of pro-longed bed rest was harmful. The cardiac

status of children who had been treated at Herrick House was determined by periodic

examinations. All the children in the study

were examined by at least one of the

authors. The medical care, however, was not

provided by the physicians who performed

these follow-up examinations. Observations

made during the first 4 years after the in. itiation of the study have been reported.3

The conclusion was reached that

abandon-ment of prolonged bed rest and restriction of activity did not appear to affect the heart adversely and may have benefited it. The

purpose of this paper is to present further

observations on the same and additional

children followed from 2 to 13 years.

SUBJECTS

Five hundred children were examined. Of

these, 140 are excluded because of the brevity

of the follow-up period (less than 2 years),

the uncertainty of the diagnosis, or the

estab-lishment of a diagnosis other than rheumatic

fever (such as congenital heart disease, sickle

cell disease, rheumatoid arthritis, or viral

myo-carditis). The remaining 360 patients form the

basis of this report.

Two hundred and sixty-nine of these

pa-tients were sent to Herrick House immediately

after clinical evidence of the acute rheumatic

process had presumably disappeared. These

children are referred to as the experimental

group throughout the remainder of this paper.

They followed the program of rapid

rehabilita-tion which has been described in detail

else-where.’ In brief, this consisted of an initial

short period at bed rest during which the

pa-tient was studied for clinical manifestations of

rheumatic activity. If certain ph’sicat findings

and laborator’ studies (especially temperature,

sleeping pulse rate, leukocvte count and

eryth-rocyte sedimentation rate) approached normal

limits, the child was allowed increasing activity

from stage 0, which permitted bathroom

priv-ileges and mild sedentary activity, to stage 4,

which permitted essentially unlimited activity

(2)

effort. Most children were advanced through

these stages ill 2 to 5 months, the rate of

advancement depending upon the child’s

to!-erance. Some children with severe lesions

could not be advanced through all stages and

remained at stage 3, or even 2, at the time of

discharge from Herrick House. The average

stay at Herrick House was 3 months.

Since it was not feasible to provide a

con-trol group by assigning alternate patients to prolonged restriction of activity, 91 patients

admitted to Herrick House as

non-convales-cents concurrently with the children in the

experimental group served as a control group.

Most of these children had been subjected to

prolonged periods of bed rest before coming

to Herrick House, and had been severely

re-stricted

by

their physicians or parents to the

point of becoming “cardiac cripples”

unneces-sarilv. This group had not been medically

managed in a uniform manner according to a

preconceived plan as were the convalescent group, hence did not form a well designed control group. Nevertheless, since they had been subjected to prolonged restriction of

ac-tivity, they were used as the only available

concurrent control group with which to com-pare the group placed on the rapid

rehabilita-tion program.

METHOD OF EVALUATION

OF THE CARDIAC STATUS

The cardiac status of patients at the final

follow-up examination was compared with

initial findings at the time of admission to

Herrick House. The heart was considered to be

better, same, or worse on the basis of three

types of changes: 1) significant changes in

murmurs on auscultation, 2) significant changes

in heart size as observed by fluoroscopy and

on teleoroentgenograms, and 3) significant

changes in blood pressure caused by aortic

insufficiency. All these observations were made

and evaluated by the three clinicians

conduct-ing this study. The electrocardiogram was not

available for each child from the beginning

of the study and was, therefore, not used in evaluation of the cardiac status.

An arbitrary scoring system was devised as follows. Since the development of dynamically

significant aortic insufficiency and the

appear-ance of cardiomegalv were considered to in-dicate more serious heart disease than did

changing murmurs, the scoring system was

weighted accordingly.

Changes in murmurs were graded as -2,

-1, 0, +1, +2. 0 indicated no significant

change, - indicated changes for the worse,

and + for the better. A grade 1 change

mdi-cated the development of a significant

mur-mur consistent with minimal to moderate

or-ganic disease, grade 2 with moderately severe

to severe disease.

Changes in the cardiac size at the time of

the last examination were graded on a scale

-5, -2, 0, +2, +5. 0 indicated no change,

- illcrease and + decrease in heart size.

Crade 2 implied slight to moderate and grade

5 marked changes in heart size.

The appearance of a widened pulse

pres-sure (70 mm Hg or more) and decreasing

diastolic systemic pressure (50 mm Hg or less)

caused by aortic insufficiency was graded -5.

The total score was then obtained by adding

the scores based on murmur, size and blood

pressure changes. A negative total score

re-suited in a classification as worse, positive

score as better, and 0 score as same. Though

the method of scoring was arbitrary, in

prac-tice little doubt was encountered as to the

validity of the final classification because of

opposite changes, e.g. , in size and murmur.

RESULTS

The changes in the physical findings of

the patients with cardiac deterioration are

tabulated in Table I.

In attempting to assess the effect on the

heart of abandoning prolonged rest, other

factors known to influence the cardiac

status had to be considered. We therefore

analyzed the adequacy of medical care, the

use of prophylactic medication against

in-fection by group A beta hemolytic

strepto-cocci, the number of rheumatic recurrences, chronic myocarditis and intervening suba-cute bacterial endocarditis, the age distri-bution of patients, and the number of years in the follow-up study.

The medical care received by the 269

ex-perimental patients following discharge

from Herrick House was judged to be good

in 78%, poor in 19%, and unknown in 3%,

(3)

TABLE I

CHANGES IN PHYSICAL FINDINGS OF PATIENTS WITh C.SRDIAc I)ETEuI0RATI0N

111*

St BP** S&M ‘f.flp

s&zp

M(tS&BP Totals

Experimental

Entire grp 17 19 1 24 2 2 4 69

Excluding recurrences, chronic IflyOear(litis,

and subacute bacterial endocarditis 8 5 0 6 1 0 1 21

Control

Entire group 7 17 1 7 3 1 1 37

Exelu(lmg recurrences, (lironic Iliyocar(Iitis,

811(1 subacute bacterial endoearditis 5 4 0 2 2 0 0 13

* M = murmur consistent with increased cardiac damage.

t S= increased heart size.

** BP = increased pulse pressure with significant fall in diastolic pressure.

good, 8% poor, and 5% unknown quality of detected infection with this organism might

medical care. Thus, the percentage of pa- affect the heart adversely. In one well

con-tients receiving poor medical care was trolled study 95% of children with an acute

greater in the experimental group

(

Table attack of rheumatic fever recovered

with-II). out evidence of carditis. None of these

chil-Prophylactic medication to prevent infec- dren had carditis at a 5-year follow-up if tion by group A beta hemolytic streptococci they received prophylaxis continuously

dur-has clearly been shown to prevent rheu- ing that 5 years.4 We could not assess this

matic recurrences and consequent addi- factor in our study because the children, tional heart damage. Even in the absence of after leaving Herrick House, were managed frank rheumatic recurrence, clmnically un- by various clinics or private physicians. The

TABLE II

COMPARISON OF MEDICAL CutE

(‘ardiac Status Adequacy of .i!edieal (‘are

Experimental

Better

(‘269) Same

Worse

Totals

Good Poor Unknown

‘29

128

10

27

0

6

54 14 1

211 (78%) 51 (19%) 7 (3%)

(‘oat rol

Better 10 I

(91) Same 37 3

Worse 32 3

Totals 79 (87%) 7 (8%)

0

3

2

(4)

Experimental

Entire group (269)

Better Same Worse

39 (14%) 161 (60%) 69 (26%)

Excluding recurrences, subacute bacterial

en-docarditis, and chronic myocarditis (170) 31(18%) 118 (69%) 21(12%)

Control

Entire group (91) 11 (12%) 43 (47%) 37 (41%)

Excluding recurrences, subacute bacterial

en-docarditis, and chronic myocarditis (52) 10 (19% 29 (56%) 13 (25%)

TABLE III

CARDIAC STATUS OF EXPERIMENTAL AND CONTROL GROUPS AT THE TIME OF THE FINAL EXAMINATION

length of time they received prophylactic medication and the consistency with which

they received it is unknown. Since

prophy-lactic medication was rarely used at the

time this study was begun, and since an

analysis of the records of 100 children

ex-amined in 1955’ showed that two-thirds

were not receiving such medication even though it had become the accepted method

of management at that time, it is reasonable

to assume that during a great percentage of

the patient-years involved in this study

pro-phylaxis was not used in either group. The cardiac status of the experimental group was compared to that of the control group. This was done both before and after excluding all patients with chronic

myocar-ditis, healed subacute bacterial endocarditis,

and rheumatic recurrences after the initial

examination. Chronic myocarditis

undoubt-edly remained undetected in some patients

since there is no specific test available to detect this disease process. For the same

reason this diagnosis cannot be definitely

established except by postmortem

examina-tion. Nonetheless, this diagnosis appeared

justified and was made whenever

consider-able cardiomegaly developed during an acute attack of rheumatic fever and per-sisted indefinitely or whenever moderate to

severe cardiomegaly was apparently not

attributable solely to valvular damage. The

results are shown in Table III. Twenty-six

percent of tile entire experimental group

were worse as compared to 41% of the entire

control group. In the more restricted group

excluding recurrences, subacute bacterial endocarditis and chronic myocarditis, 12%

of the experimental group were worse as

compared to 25% of the control group. The number of patients in some groups is small,

and hence, of limited statistical value. It is

to be noted, however, that the results are in

the same direction whether comparing the

entire group or the more restricted groups.

The factor of age distribution was

con-sidered and the mean ages of the children in each group calculated (Table IV). The

numbers of children in some groups are so small that the average age of the group

has less statistical value than it would have

for larger groups. Nevertheless, the average

age in all groups is sufficiently close so that

age could not be an important factor in

de-termining the cardiac status.

One hundred sixty-nine of the

experi-mental group of patients were followed for

2 to 4 years inclusively, 97 for 5 to 9 years,

and three for 10 or more years. In the

con-trol group 28 were followed for 2 to 4 years,

57 for 5 to 9 years, and six for 10 or more

years. On the whole, the experimental

group was observed for a shorter period of

time

(

Table V). The poorer cardiac status

of the control group conceivably could be

ascribed to changes which become

appar-ent only after a long time interval.

Com-parison of the children followed for five

years or longer

(

Table VI) showed that in

(5)

2 to

Experimental 169 (63%) 97 (36%) 3 (1%) 269 (100%)

Control 28(31%)

TABLE IV

MEAN AGE IN YEARS OF PATIENTS AT LAST EXAMINATION

(Number of patients in each group is enclosed in parenthesis.)

Cardiac Status

Better Same Worse

Experimental

Entire group 14 (39) 14 (161) 15 (69)

Excluding recurrences, subacute bacterial

en-docarditis, and chronic myocarditis 14 (31) 14 (118) 16 (21)

Control

Entire group 18 (11) 15 ( 43) 17 (37)

Excluding recurrences, subacute bacterial

en-docarditis, and chronic myocarditis 18 (10) 14 ( 29) 18 (13)

51% remained the same, and 33% were

worse; whereas in the control group 14%

were better, 40% the same, and 46% were

worse.

The groups followed 5 years or more

were small and the difference observed in

cardiac status cannot be considered statisti-caliy significant. On the other hand, there is

certainly no evidence that prolonged bed

rest favors cardiac recovery.

The distribution of patients according to

sex and race are shown in Table VII. The

ratio of numbers of males to females in both groups is roughly the same. The ratio of

Negroes to whites was higher in the

ex-perimental group. This would tend to affect

the cardiac status of the experimental group

unfavorably if one assumes that the

eco-nomic status of the Negroes was poorer

than that of the whites and therefore a

poorer cardiac prognosis followed. We did

not analyze this factor of variable economic

status further, however.

COMMENT AND CONCLUSIONS

The current trend toward permitting

phy-sical activity during acute rheumatic fever

lends additional importance to the finding

that prolonged bed rest appears

unneces-sary as far as the heart is concerned. The

timitations of our study are well

appreci-ated by the authors. Variables known to

af-feet cardiac status could not be rigidly

con-trolled, nor is there a completely satisfac-tory concurrent control group available. Nevertheless, analysis of our data shows

that the control group and experimental group were comparable in 1) quality of

medical care received after leaving Herrick

House, 2) use of antistreptococcal

prophy-laxis, 3) incidence of recurrences, chronic

myocarditis, and subacute bacterial

endo-TABLE V

DISTRIBUTION OF PATIENTS ACCORDING TO YEARS IN FOLLOW-UP STUDY

Years Followed

5 to 9 10 or more T tal

(6)

Better

Experimental 16(16%)

Control (91)

TABLE VI

CARDIAC STATI-S OF PATIENTS FOLLOWED LONGER TIIAN 5 EARS

(‘ardiac Status

Same Horse Total

51 (51%) 33(33%) 100

Control 9(14%) 25 (40%) ‘29 (46%) 63

TABLE VII

SEX AND RACE 1)ISTRIBI-TION

Male Female While Negro

Experimental (269) 154 (57%) 115 (43%) 186 (69%) 83 (31%)

53(5l%) 38 (42%) 75 (82%) 16 (18%)

carditis, 4) age distribution, and 5) number

of years in the follow-up study. Any bias

introduced by these variables which are

known to influence the cardiac status

tended to be favorable to the control group.

Nevertheless, in patients whose restriction

of physical activity was rapidly lifted after

subsidence of rheumatic activity, no

dele-terious effect on the heart could be

demon-strated. The results rather suggest a

benefi-cia! effect. This confirms the conclusion of

our previous report on a shorter

observa-tion period.

Our findings lend support to the

conten-tion that prolonged bed rest and restriction

of activity after an acute attack of

rheu-matic fever is not necessary for optimal

healing of the injured heart; therefore, the

economic burden and psychologic damage of such enforced inactivity’ can be safely

avoided in most instances by permitting

early return to normal activity. Additional

long-term, well controlled clinical studies

are needed to determine, first, whether per-mitting physical activity during acute rheu-matic fever, including myocarditis, has any

effect upon the ultimate cardiac status and,

secondly, whether tile timing and amount

of such physical activity influence the

con-sequent heart lesions.

Acknowledgment

Mrs. Charlotte Kobrill, social worker on the

staff of Herrick House, assisted in obtaining

and tabulating the data. Mrs. Edwin Eells,

Director, and Drs. Oglesby Paul and Louis N.

Katz, members of the Medical Advisory Board,

Herrick House, gave advice and assistance in

this stud.

REFERENCES

1. Robertson, H. F., Schmidt, R. E., and

Feir-ing, W. : The therapeutic value of earls’

physical activity in rheumatic fever. Am.

J.M.

Sc., 211:67, 1946.

2. Gibson, M. L., and Fisher, G. R. : Early

ambulation in rheumatic fever (abstract).

A.M.A.

J.

Dis. Child., 96:575, 1958.

3. Simon, A.

J.,

Mack, I., and Rosenbium, P.:

Accelerated rehabilitatioll ill rheumatic

fever. Am.

J.

Dis. Child., 83:454, 1952.

4. Stollerman, C. H.: Personal communication.

5. Lendrum, B. L., alld Kobrin, C.:

Preven-tion of recurrent attacks of rheumatic

fever: problems revealed by long-term

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1959;24;389

Pediatrics

Bessie L. Lendrum, Albert J. Simon and Irving Mack

HEART DISEASE PRESENT 2 TO 14 YEARS LATER

RELATION OF DURATION OF BED REST IN ACUTE RHEUMATIC FEVER TO

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(8)

1959;24;389

Pediatrics

Bessie L. Lendrum, Albert J. Simon and Irving Mack

HEART DISEASE PRESENT 2 TO 14 YEARS LATER

RELATION OF DURATION OF BED REST IN ACUTE RHEUMATIC FEVER TO

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