The relative importance of physical activity was first noted in 1772, when the famous physician William Heberden published a report describing a 6-month exercise program consisting of 30 minutes of daily sawing for a male patient with “chest disorder.”1 One can surmise that the diagnosis was coronary artery disease and that the patient was probably experiencing angina pain or recovering from a myocardial infarction (MI). In 1799, an English physician, C. H. Parry, independently noted the beneficial effects of physical activity in his patients who suffered from chest pain.2 The reaction by the medical community to this notion met with much resistance and was not assimilated into practice. In 1912, Herrich gave the first clinical description of an acute MI and encouraged physicians to reevaluate the role of physical activity in the treatment of patients with coronary heart disease.3 However, the medical community expressed fear that increased physical exertion could lead to increased risk of ventricular aneurysm, myocardial rupture, or heightened arterial hypoxemia. The conservative treatment approach of 6 to 8 weeks of bed rest for patients with MI continued to be the common protocol well into the 20th century.
The debate over the benefits of physical activity for patients with MI persisted and won small gains in the late 1930s when two physicians G. K. Mallory and P. D. White3 found that the necrotic myocardial region was converted into scar tissue after approximately 6 weeks. Accordingly, they prescribed a minimum of only 3 weeks of bed rest for patients with uncomplicated MI and limited physical activity after hospital discharge. Stair climbing was prohibited, in some cases for up to a year. It was becoming clear, however, that, during the convalescent period, patients were becoming invalid due to either fear or lack of patient education. Follow-up medical management provided little advice regarding exercise tolerance, stress management, or education about the disability and its limitations. Typically, patients never returned to work and were put on long-term disability. This resulted in patients with MI being viewed as nonproductive members of society.
Most of the research performed during the first three decades of the 20th century centered both on identifying better methods of diagnosing and classifying cardiac disorders and on developing simple testing for “circulatory efficiency.” Little attention was directed toward identifying the risk factors associated with coronary artery disease or to establishing its cause.4
By the late 1930s, significant numbers of the labor force had retired on disability due to cardiac problems. The New York State Employment Service, concerned about the growing numbers of men on disability, decided to evaluate the reason for lack of return to work in patients with heart disease.5 A state survey revealed that 80% of the individuals receiving disability benefits were patients with heart disease who had not returned to their jobs. Furthermore, only 10% had attempted ...