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 childrenwitil 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
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 thepoint 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%,
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 TotalsExperimental
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 recoveredwith-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
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 statusof 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 in2 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
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