Document Type : Original Articles


1 Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.

2 Department of Physiotherapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

3 Department of Physiotherapy, Iran University of Medical Sciences, Tehran, Iran

4 Department of Physiotherapy, School of rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran


Background: Coronary Artery Bypass Grafting is an effective treatment for reducing symptoms and mortality in coronary artery patients.Although patients experience post sternotomy complications such as musculoskeletal disorders. So, the aim of this study was to compare the head, neck and upper trunk postures between patients who underwent coronary artery bypass grafting and healthy individuals.
Methods: In this cross-sectional case-control study, twenty-one men (56.38 ± 8.64 years) were randomly selected from among patients who had been referred to Al-Zahra Cardiac Rehabilitation Center in Shiraz and undergone coronary artery bypass grafting (CABG), and the angles of forward head, thoracic kyphosis, and rounded shoulder were measured. Twenty healthy men (51.70 ± 10.40 years) were also evaluated and compared in terms of the above variables. This study was designed and conducted as a pilot. The angles of the forward head and rounded shoulder were assessed by placing reflective markers on the body and processing the images by Digimizer MedCalc software, version 4.6.1. Thoracic kyphosis angle was measured by a flexible ruler. The Persian version of the SF36 questionnaire was used to assess the quality of life, and the Kolmogorov-Smirnov test to verify the normal distribution of data. Independent sample t-test and Mann-Whitney test were used for between-group comparison for data with normal and non-normal distribution, respectively.
Results: The comparison of the forward head, rounded shoulder, and thoracic kyphosis angles showed no significant difference between post-surgical and healthy subjects (P> 0.05). Patients' quality of life was significantly different from that of the control group in all aspects, except for general and mental-emotional health (p <0.05).
Conclusion: There was no significant difference between the case and control groups in the angles of forward head, thoracic kyphosis, and rounded shoulder. Patients who underwent CABG, however, experienced a significant reduction in their quality of life compared to the control group. Therefore, it seems necessary to pay attention to patients and find solutions to manage and improve various aspects of life, such as physical and mental health.


1.         Hatchett R, Thompson DR. Cardiac nursing: a comprehensive guide.1th ed: Churchill Livingstone; 2002.p45.
2.         Hasanzadeh M, Sabzevari A, Vahedian M. Mortality and morbidity followed coronary artery bypass surgery. Journal of Torbat Heydariyeh University of Medical Sciences. 2013;1(1):59-65.
3.         Sethares KA, Chin E, Costa I. Pain intensity, interference and patient pain management strategies the first 12 weeks after coronary artery bypass graft surgery. Appl Nurs Res 2013;26(4):174-9.
4.         Askari B, Mehdizade H, Komasi S. Evaluation of determinants of mortality in patients undergoning coronary artery by pass graft surgery in Urmia Seyed-al- Shohada Heart Center. RJMS 2019; 25(11):23-33.
5.         Jamieson M, Wilcox S, Webster W, Blackhurst D, Valois RF, Durstine JL. Factors influencing health‐related quality of life in cardiac rehabilitation patients. Prog Cardiovasc Nurs 2002;17(3):124-54.
6.         LaPier TK, Schenk R. Thoracic musculoskeletal considerations following open heart surgery. Cardiopulm Phys Ther J 2002;13(2):16.
7. Sadeghi S, Bozorgzad P, Ghafourian AR, Ebadi A, Razmjoei N, Afzali M, et al. Effect of foot reflexology on sternotomy pain after coronary artery bypass graft surgery. Critical care nursing 2009;2(2):51-4.
8.         Hunt JO, Hendrata MV, Myles PS. Quality of life 12 months after coronary artery bypass graft surgery. Heart Lung 2000;29(6):401-11.
9.         Bordoni B, Marelli F, Morabito B, Sacconi B, Severino P. Post-sternotomy pain syndrome following cardiac surgery: case report. Pain Res 2017;10:1163-1169.
10.       Silva M, Feuser M, Silva M, Uhlig S, Parazzi P, Rosa G, et al. Pediatric cardiac surgery: what to expect from physiotherapeutic intervention? Braz J Cardiovasc Surg 2011;26(2):264-72.
11.       Artinian NT, Duggan CH. Sex differences in patient recovery patterns after coronary artery bypass surgery. Heart Lung 1995;24(6):483-94.
12.       Edell-Gustafsson U, Hetta J, Arén C, Hamrin E. Measurement of sleep and quality of life before and after coronary artery bypass grafting: a pilot study. Int J Nurs Pract 1997;3(4) : 239-46.
13.       Moore SM. A comparison of women's and men's symptoms during home recovery after coronary artery bypass surgery. Heart Lung 1995;24(6):495-501.
14.       El-Ansary D, Adams R, Ghandi A. Musculoskeletal and neurological complications following coronary artery bypass graft surgery: A comparison between saphenous vein and internal mammary artery grafting.  Aust J Physiother 2000;46(1):19-25.
15.       Herrera-Soto JA, Vander Have KL, Barry-Lane P, Woo A. Spinal deformity after combined thoracotomy and sternotomy for congenital heart disease. J Pediatr Orthop 2006; 26(2):211-5.
16.       Ruiz-Iban MA, Burgos J, Aguado HJ, Diaz-Heredia J, Roger I, Muriel A, et al. Scoliosis after median sternotomy in children with congenital heart disease. Spine 2005;30(8):E214-8.
17.       Glotzbecker MP, Gold M, Puder M, Hresko MT. Scoliosis after chest wall resection. J Child Orthop 2013;7(4):301-7.
18.       Akıncı B, Yeldan İ, Bayramoğlu Z, Akpınar TB. The effects of posture and relaxation training on sleep, dyspnea, pain and, quality of life in the short-term after cardiac surgery: a pilot study. Turk Gogus Kalp Dama 2016;24(2):258-65.
19.       Hunt JO, Hendrata MV, Myles PS. Quality of life 12 months after coronary artery bypass graft surgery. Heart Lung 2000;29(6):401-11.
20.       Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B. The Short Form Health Survey (SF-36): translation and validation study of the Iranian version. Quality of life research. 2005;14(3):875-82.
21.       de Oliveira TS, Candotti CT, La Torre M, Pelinson PPT, Furlanetto TS, Kutchak FM, et al. Validity and reproducibility of the measurements obtained using the flexicurve instrument to evaluate the angles of thoracic and lumbar curvatures of the spine in the sagittal plane.Rehabil Res Pract 2012;2012.1-9.
22. Azadinia  F, Kamyab M, Behtash H, Ganjavian M, Mirzazadeh-Javaheri M. The validity and reliability of flexicurve for measuring kyphosis 2012; 8(4): 1-10.
23. Taghizadeh S, GhafariNejad F, Emami F, ImaniFard T, Hoseini, SE.The Effects of Neck Stabilization Exercises to Improve Forward Head Posture in 20-27 Years Old Female Students.J Res Rehabil Sci 2013;9(7):1222-1231.
 24.Youefi M, Il beigi S, Mehrshad N, Afzalpoor MS. Diagnosis of Spinal Column Abnormalities by Image processing of Reflective Markers Set on Spinus Process.Journal of excercise sciences and medicine 2010;4:73-89.
25.       Kendall FP, McCreary EK, Kendall HO. Muscles, Testing and Function: Testing and Function: Lippincott Williams and Wilkins; 1983.p112.
26.       Katzman WB, Vittinghoff E, Ensrud K, Black DM, Kado DM. Increasing Kyphosis Predicts Worsening Mobility in Older Community‐Dwelling Women: A Prospective Cohort Study. J Am Geriatr Soc 2011;59(1):96-100.
27.       Willner S. Spinal pantograph-a non-invasive technique for describing kyphosis and lordosis in the thoraco-lumbar spine. Acta Orthop Scand. 1981;52(5):525-9.
28.       Singla D, Veqar Z, Hussain ME. Photogrammetric Assessment of Upper Body Posture Using Postural Angles: A Literature Review. J Chiropr Med 2017;16(2):131-138.
29.       Kim HY. The Examination of Reliability of Lower Limb Joint Angles with Free Software ImageJ. J Ergon Soc Korea. 2015;34(6):583-95.
30.       Guan X, Fan G, Wu X, Zeng Y, Su H, Gu G, et al. Photographic measurement of head and cervical posture when viewing mobile phone: a pilot study. Eur Spine J 2015; 24(12): 2892-8.
31.       Xu L, Hwang B, Kim T. The Effect of postural correction and visual feedback on muscle activity and head position change during overhead arm lift test in subjects with forward head posture. JKPT. 2019;31(3):151-6.
32.       Silva AG, Punt TD, Sharples P, Vilas-Boas JP, Johnson MI. Head posture and neck pain of chronic nontraumatic origin: a comparison between patients and pain-free persons. Arch Phys Med Rehabil 2009;90(4):669-74.
33.       Ruivo RM, Pezarat-Correia P, Carita AI. Cervical and shoulder postural assessment of adolescents between 15 and 17 years old and association with upper quadrant pain. Braz J Phys Ther 2014;18(4):364-71.
34.       Manhal S, Sirajudeen MS, Pillai PS, Nair HR, Marla J. Occurrence of shoulder disorders among postcoronary artery bypass surgery patients in India. AMHS 2015;3(1):34-39.
35.       Mendes RG, Simões RP, Costa FDSM, Pantoni CBF, Di Thommazo L, Luzzi S, et al. Short-term supervised inpatient physiotherapy exercise protocol improves cardiac autonomic function after coronary artery bypass graft surgery–a randomised controlled trial. Disabil rehabil 2010;32(16):1320-7.
36.       Silva CR, Andrade LB, Maux DA, Bezerra AL, Duarte MC. Effectiveness of prophylactic non-invasive ventilation on respiratory function in the postoperative phase of pediatric cardiac surgery: a randomized controlled trial. Braz J Phys Ther 2016;20(6):494-501.
37.       Kumari AA, Ashok C, Sekhar PKC. Physical therapy for post coronary after artery bypass grafting complications: A case report. IJPR 2013; 01(01):20-22.
38.       Dehdilani M, Gol MK, Hashemzadeh K. Effects of Stretching Exercises on Upper Crossed Syndrome in Women after a Coronary Artery Bypass Graft. Crescent Journal of Medical and Biological Sciences 2019;6:350-354.
 39.      Akıncı B, Yeldan İ, Bayramoğlu Z, Akpınar TB. The effects of posture and relaxation training on sleep, dyspnea, pain and, quality of life in the short-term after cardiac surgery: A pilot study. Turk Gogus Kalp Dama 2016;24(2):258-265.
40.       Goodman CC. Screening for medical problems in patients with upper extremity signs and symptoms. J Hand Ther 2010;23(2):105-26.

41. Montazer Ghaem  H, Asar O, Safaei N. Assessing patient's quality of life after open hart surgery in Bandar Abbas, Iran. Hormozgan Medical Sciences 2011;15(4):254-9.

42.       Johansson P, Dahlström U, Broström A. Factors and interventions influencing health-related quality of life in patients with heart failure: a review of the literature. Eur J Cardiovasc Nurs. 2006;5(1):5-15.