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Bouncing Back
Monday April 28, 2008


Rheumatic fever (RF) is a potentially heart-damaging disease that starts out with deceptively minor symptoms. Often beginning with no more than a sore throat, it can quickly become a widespread infection that triggers an acute inflammatory process affecting tissues throughout the body, including the heart, brain, joints, and skin. School-aged children typically are affected, especially those between the ages of 5 and 15.

The most serious complication of RF is rheumatic heart disease, a lifelong condition that causes cardiac valve insufficiency, pericarditis, and heart failure in as much as 39 percent of patients. Rheumatic heart disease, which may be detected with echocardiography, most commonly affects the mitral valve (65 to 70 percent of affected patients), but also may affect the aortic valve (25 percent). Although valve damage may take years to develop after the initial acute infection, RF remains the primary cause of mitral valve replacement in U.S. adults.

RF is caused by group A streptococcus bacteria, the same gram-positive organisms responsible for strep throat. But now, even that painful, swollen throat infection is no longer considered a risk to children, because rapid treatment with penicillin reduces the possibility of subsequent cardiac complications.

However, in developing countries the risk of RF continues unabated; worldwide, RF is thought to affect 5 to 30 million children, adolescents, and young adults. It is estimated that there may even be an upswing in RF cases in some parts of the world.

For most physical therapists, these young patients won’t be seen in practice until after they have recovered from the acute infection, and at that point the goal of physical therapy is strengthening and endurance activities once all clinical symptoms (typically fever, dyspnea, chest pain, joint pain, and cough) have resolved and laboratory and imaging findings have normalized. Many children develop a heart murmur from valve damage, which may or may not resolve within five years of the initial diagnosis, and which must be tracked.

Cardiac care

Although most children with acute RF are restricted to bed rest for at least five weeks or until symptoms have resolved, once movement is approved by the treating physician, children are encouraged to participate in gradual, progressive physical activity.

Treating children with cardiac conditions requires monitoring, patient motivation, and family involvement, says Joe Schreiber, PT, PhD, PCS, assistant professor of physical therapy at Chatham College in Pittsburgh. Schreiber, who developed a community-based treatment program with his colleagues called “Off the Couch” for children with disabilities, notes that progress can be gradual. “Most of the time we are taking small steps,” he says.

For young cardiac patients, it is important to keep a careful eye on pulse oximetry and heart rate every step of the way, Schreiber adds.

Family education has traditionally included encouragement in good dental hygiene to reduce gum sensitivity and bleeding that is thought to increase the child’s risk of heart damage. Patients with rheumatic heart disease were asked to take antibiotics before routine dental procedures to protect damaged heart valves from bacterial growth; however, in April 2007 the American Heart Association modified its guidelines. Now, prophylactic antibiotics are recommended only for patients with previous bacterial endocarditis, prosthetic heart valves, or certain specific types of congenital heart disease.

Reaching for recovery

Infants and toddlers with heart problems have been shown to benefit from touch and movement. Suzann Campbell, PT, PhD, FAPTA, professor and head of the physical therapy department at the University of Illinois at Chicago, recalls a time when a baby with heart disease responded to a very simple exercise intervention, trying to touch a little toy she brought along for crib-side visits. “It was a little white dog with black spots, very high contrast,” she recounts. “[The baby] had a very serious problem, but he liked the toy, and worked hard reaching toward it.”

Toys are a great aid to get children moving, even little ones who might otherwise have trouble mastering a muscle-building protocol, agrees Anne Mejia Downs, PT, MPH, CCS, assistant professor at the Krannert School of Physical Therapy at the University of Indianapolis. As to what works best, “There is no hard-and-fast guideline,” she stresses. Instead, Downs advises tailoring the toy to the child’s interests while remaining age-appropriate.

For very young patients, she recommends Cranium Hullabaloo, a game that directs children to navigate across different colored shapes. There is a game called Dance Dance Revolution, which instructs children how to move their feet while a bouncy pop song plays. For older children, the classic game of Twister can be fun, Downs says.

Like Schreiber, she cautions that close monitoring during activity is essential. Checking heart rate, watching for shortness of breath, and noting changes in skin tone are important visual indicators of cardiac stress when working with children, she says.


    • Ferrieri, P. 2002. Proceedings of the Jones Criteria Workshop. Circulation 106:2521-3.
    • Marijon, E., P. Ou, D. S. Celermajer, et al. 2007. Prevalence of rheumatic heart disease detected by echocardiographic screening. New Engl J Med 357:470-6.
    • Schreiber, J., G. Marchetti, and T. Crytzer. 2004. The Implementation of a Fitness Program for Children with Disabilities: A Clinical Case Report. Pediatr Phys Ther 16(3): 173-9.

Anne Scheck is a medical writer for the Gannett Healthcare Group. To comment on this story, send e-mail to

Monday April 28, 2008
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