Disability and Rehabilitation

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Myofascial release in patients during the early

postoperative period after revascularisation of
coronary arteries

Maria Ratajska, Małgorzata Chochowska, Anita Kulik & Paweł Bugajski

To cite this article: Maria Ratajska, Małgorzata Chochowska, Anita Kulik & Paweł Bugajski (2019):
Myofascial release in patients during the early postoperative period after revascularisation of
coronary arteries, Disability and Rehabilitation, DOI: 10.1080/09638288.2019.1593518

To link to this article: https://doi.org/10.1080/09638288.2019.1593518

Published online: 03 May 2019.

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DISABILITY AND REHABILITATION
https://doi.org/10.1080/09638288.2019.1593518

ORIGINAL ARTICLE

Myofascial release in patients during the early postoperative period after

revascularisation of coronary arteries
Maria Ratajskaa, Małgorzata Chochowskab, Anita Kulikb and Paweł Bugajskia,c
a
Department of Cardiovascular Surgery, Strus Hospital Poznan, Poznan, Poland; bDepartment of Rehabilitation, Poznan University School of
Physical Education, Gorzow Wielkopolski, Poland; cPoznan University of Medical Sciences, Poznan, Poland

ABSTRACT ARTICLE HISTORY

Purpose: The evaluation of the impact of soft tissue manual therapy with a myofascial release on pul- Received 3 June 2018
monary function, postoperative pain, fatigue, breathing difficulties and physical fitness, in patients during Revised 6 March 2019
the early postoperative period after coronary artery bypass grafting and off-pump coronary artery bypass Accepted 7 March 2019
grafting surgery.
KEYWORDS
Materials and methods: The study included 80 subjects (59 males) with an average age of 64.13 years Ischemic heart disease;
old. They were randomised into two groups: group I (n ¼ 40) received a conventional form of rehabilita- revascularisation of
tion and group II (n ¼ 40) additionally, from day 3 to day 6 post-surgery, was provided the Carol coronary arteries;
Manheim form of myofascial release. Subjects were evaluated three times: before the surgery, on day 4 rehabilitation; myofascial
and 6 post-surgery. Using the visual analogue scale, the following symptoms were measured: pain inten- release; spirometry
sity, breathing difficulties and level of physical endurance. Fatigue after performing physical exercises was
measured using the Borg scale. Spirometry was used to measure the one-second forced expiratory vol-
ume and forced vital capacity.
Results: Positive changes were observed in both groups with regard to all analysed variables. However,
group II compared to group I showed a significantly greater improvement (p < 0.05; the Mann–Whitney U
test) in relation to: pain intensity on day 4 (mean 5.46 vs 6.58) and on day 6 (mean 3.05 vs 5.35) after the
surgery; lower breathing difficulties on day 6 post-surgery (mean 4.08 vs 5.63); limiting physical fitness on
day 6 post-surgery (mean 6.35 vs 5.13). Between the condition prior to the surgery and day 6 post-sur-
gery in group II compared to group I, there was a significantly smaller (p < 0.05; Student’s t-test) decrease
in one-second forced expiratory volume (mean 0.65 vs 0.9 L/s) and the volume of forced vital capacity
(mean 0.63 vs 1.33 L). Between day 4 and 6 post-surgery in group II compared to group I, there was a
significantly higher (p < 0.05; Student’s t-test) increase in the one-second forced expiratory volume (mean
0.21 vs 0.11 L/s) and forced vital capacity (mean 0.32 vs 0.12 L).
Conclusions: Implementing myofascial release techniques in the conventional form of cardiosurgical
rehabilitation might enhance the improvement in pulmonary function, lessen breathing difficulties, pain
intensity and fatigue, it might augment the increase in physical endurance among patients during the
early postoperative period after coronary artery bypass grafting and off-pump coronary artery bypass
grafting surgery.

ä IMPLICATIONS FOR REHABILITATION

1. The implementation of myofascial release techniques in conventional cardiac rehabilitation may
improve the pulmonary function in patients during the early postoperative period, after revascular-
isation of coronary arteries.
2. The adoption of myofascial release techniques in conventional cardiac rehabilitation may decrease
breathing difficulties, pain intensity, fatigue and increase the physical fitness in patients during the
early postoperative period, after the revascularisation of the coronary arteries.
3. The implementation of myofascial release techniques in conventional cardiac rehabilitation may
enhance patients’ improvement during the early postoperative period, after the revascularisation of
the coronary arteries.

Introduction
Coronary revascularisation includes percutaneous coronary inter-
vention (PCI) or coronary artery bypass grafting (CABG) and off-
pump coronary artery bypass grafting (OPCAB) surgery. These
alternative revascularisation techniques are performed to
improve survival, decrease symptoms, prevent ischemic compli-
cations, improve function and quality of life in patients suffering
from ischemic heart disease (IHD) [1, 2]. However, the applica-
tion of coronary artery revascularisation surgery entails numer-
ous possible complications. They may affect different systems
[3–5], however, most frequently they are manifested in the
respiratory system (pulmonary complications) [6]. The fact that
CABG and OPCAB surgeries require an extensive operative field,
performance of median sternotomy, the application of general

CONTACT Anita Kulik konikanita@gmail.com Poznan University School of Physical Education, Ul. Estkowskiego 13, Gorzow Wielkopolski 66-400, Poland
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 M. RATAJSKA ET AL.
anaesthesia and other factors, i.e., the patient’s age, phase of
the disease or coexisting diseases and an increase in the risk of
complications [7].
In patients with postoperative pulmonary dysfunction, an
increased respiratory frequency is observed along with shallower
breathing, inefficient coughing and hypoxemia [8]. Moreover,
there may be a decrease in the vital capacity (VC), forced vital
capacity (FVC), one-second forced expiratory volume (FEV1), FEV1/
FVC, peak expiratory flow (PEF), inspiratory capacity (IC), func-
tional residual capacity (FRC), residual volume (RV) and total lung
capacity (TLC) [9–11]. Lower spirometry results may persist even
up to 4-6 months post-surgery [12,13] and one study has shown
that they may still be present even one year post-surgery [10].
Additionally, patients may develop impairments in gas exchange,
which cause a decrease in the oxygen partial pressure (PaO2) and
an increase in the carbon dioxide partial pressure (PaCO2) in arter-
ial blood [14]. Surgical disruptions of the richly vascularised and
innervated pleura and chest wall are the causes of severe pain
after sternotomy, which further weakens the respiratory muscles,
restricts the chest, glenohumeral joint and spine mobility, as well
as impedes the expectoration of the secretion [5,15,16]. The afore-
mentioned factors as well as the patients’ fear of pain, the diasta-
sis of the sternum and the postoperative wound [17] all
contribute to the further deterioration of pulmonary function.
Due to the risk of diastasis of the sternum and postoperative
wound following a median sternotomy, in the early stage after
the surgery, the patient is not allowed to exercise in supine or
side-lying positions, or to abduct the upper extremities sideways.
According to Myers’ anatomy trains concept [18], it means that
myofascial structures forming the lateral line and the superficial
front line are excluded from therapeutic applications (Table 1). In
our previous study, we have shown that the functional condition
of these structures influences the improvement of pulmonary
function [19]. Therefore, one may suppose that using myofascial
release (MFR) techniques may be beneficial for patients post-
CABG and OPCAB. The advantage of MFR techniques are its
gentleness and non-invasiveness. During therapy one works with
fascial structures, thus, not influencing bone structures directly,
which is contraindicated in the early postoperative period after
cardiac surgeries. These techniques are comfortable and safe, they
may be applied in elderly patients and in acute conditions.
Objective
The objective of this study was the evaluation of the efficacy of
soft tissue manual therapy using MFR techniques, in accordance
to Carol Manheim, on pulmonary function and postoperative
pain, fatigue, breathing difficulties and physical fitness in patients
Table 1. Main structures of myofascial lines according to Mayers [18].
Superficial back line (SBL) Superficial front line (SFL)
Galea aponeurotica Cranial fascia
Sternocleidomastoid muscle
Sacrolumbar fascial Erector spinea Sternal fascia
Sacrotuberous ligament Sternochondral fascial
Hamstrings Rectus femoris
Gastrocnemius Quadriceps femoris
Patellar tendon
Achilles tendon Tibialis anterior
Planta fascia Short and long toe extensors
Short toe flexors
during the early postoperative period after surgical revascularisa-
tion of the coronary artery using CABG and OPCAB.
Materials and Methods
Study population
Eighty subjects were selected for the research (21 females, 59 males)
with IHD, aged 50-79 years old (mean: 64.13), who underwent CABG
(N ¼ 68) or OPCAB (N ¼ 12). The physicians who qualified the study
subjects did not know the allocation of subjects. The subjects were
randomised (urn randomisation) into two groups (GR): control group
(GR I; N ¼ 40) and the study group (GR II; N ¼ 40). Group I and II
were homogenous in terms of gender, age, education, BMI, place of
residence, character of work, number of cigarettes smoked a day
and the number of cardiac infarctions (Table 2). The study was
approved by the Bioethics Committee of the Karol Marcinkowski
Medical University in Poznan (resolution number: 171/18). The study
was registered in the Australian New Zealand Clinical Trials Registry.
Trial Id: ACTRN12618000470291.
Conventional model of rehabilitation
GR I (control) was rehabilitated using the conventional method
(see Table 3). Rehabilitation according to a conventional model
was carried out using the following scheme: PT-assisted kinesio-
therapy, one on one, face to face and 3-5 times per day for 15-
30 min (depending on the level of cardiopulmonary capacity of
each subject – the bigger the failure, the more frequent and
shorter the exercise periods and exercises performed by patients
themselves (breathing, coordination and walking – subjects noted
the total time spent on each exercise per day in a diary)), see
Table 3. The required target intensity of exercises was HR increase
from 20 to 40 (HR: min. increase 20; max. increase 40).
MFR techniques in accordance to Carol Manheim
In GR II, the conventional model of rehabilitation was comple-
mented by Carol Manheim MFR techniques, which were used
from day 3 to day 6 after the surgery (with a physical therapist,
one on one and face to face). Interventions involved the struc-
tures of the superficial front line and the lateral line, the myofas-
cial lines according to Myers, within the area of the chest wall
and the abdominal wall (see Table 1). The MFR techniques were
performed once a day for 30 minutes.
Each time the physical therapist performed sixteen consecutive
MFR techniques in accordance to Carol Manheim [20]:
1. Relaxing the scalene muscles and the lateral part of cervical
fascia – cross technique (Figure 1),
Lateral line (LL) Spiral line (SL)
Splenius capitis Splenius capitis and cervicis
Sternocleidomastoid Rhomboids
Intercostal Serratus anterior
Oblique abdominal muscles Oblique abdominal muscles
Gluteus maximus Tensor fascial lata
Tensor fascial lata
Iliotibial band Iliotibial band
Tibialis anterior
Hip abductors Peroneus brevis
Peroneal group Biceps femoris
Lateral compartment of the lower leg Sacrotuberous ligament
Sacrolumbar fascia
Erector spinae
 MYOFASCIAL RELEASE IN PATIENT AFTER CABG AND OPCAB 3

Table 2. Characteristics of the patients from GR I and GR II.

Group I (control) Group II (study)
Coefficient N ¼ 40 N ¼ 40 p
Gender (F/M) 11/29 10/30 0.8474
Age (years) (min/max /
x ) 52/79/65,5 50/78/62.75 0.0836
Place of residence (V /C/PC) 11/19/10 11/18/11 0.9962
BMI (kg/m2) (min /max /
x ) 20.56/34.97/28.26 19.68/34.25/27.32 0.0467
Education (P/V/S/T) 7/17/8/8 8/12/10/10 0.6033
Work character (M /O/R-P) 8/9/23 9/13/18 0.3944
Smoking (cigarette/day) (0/1-20/21-40) 30/10/0 29/10/1 0.8099
Number of myocardial infarction (0/1/2 ) 19/18/3 18/19/3 0.8474
Type of surgery (CABG/OPCAB) 35/5 33/7 0.6474
Distal anastomoses – arterial bypasses (yes/no) 27/13 34/6 0.0933
Distal anastomoses – venous bypasses (n) 0/4/1,85 0/4/1,75 0.4476
(min /max /
x )
Total time of extracorporeal circulation (min.) 0/183/86 0/183/70 0.0611
(min /max /
x )
Total time of clamping aorta (min.) 0/121/49 0/120/40 0.3052
(min /max /
x )
Duration of surgery (min.) 110/435/196 120/335/183 0.1054
(min /max /
x )
Duration of hospitalisation in ICU (h) 17/168/44 18/119/40 0.8889
(min /max /
x )
Duration of hospitalisation (days) (min /max /
x ) 8/28/13.45 8/40/15.27 0.5018
Ejection fraction according to ECHO (EF) (%) 35/66/51 32/68/48 0.2156
(min /max /
x )
Euroscore (min /max /
x ) 0.55/23.66/1.95 0.53/7.88/1.54 0.9347
NYHA on discharge (min /max /
x ) 2/4/2.15 2/4/2.1 0.5352
Test U-Mann-Whitney.
F: female , M: male; V: village; C: city, PC: provincial city; P: primary, V: vocational, S: secondary, T: tertiary; M: manual work,
O: office work, R-P: retired or pensioner;
x : arithmetic mean.

Table 3. Rehabilitation scheme following cardiosurgical interventions – conventional method.

Day after surgery Position Rehabilitation
Day 1 Seated or half-seated on the patient’s bed (in Breathing exercises
Intensive Care) – 4 times a day – tapping,
– exercising efficient coughing and drainage of the
bronchial tree,
– breathing exercises (active exercises, active-
assisted, active with resistance adjusted to the
patient’s individual condition) via diaphragmatic
track, chest breathing and abdominal breathing
– anticoagulation exercises for lower and upper
extremities
– active exercises of small and large muscle groups
of lower and upper extremities (without lifting the
arms upwards and sideways, protection of the
sternum and postoperative wound)
– exercising forceful breathing (inflating a ball or a
balloon) – patient does it on their own every half
an hour,
– isometric exercises,
Day 2 – seated on a bed Breathing exercises (as above)
– seated on a bed with lower extremities hanging Walking
down, Upright standing position at the patient’s bed and
– walking (following the removal of drainage from first walks in the hospital room , next walking
mediastinum or pleura) down the corridor with assistance and
then without
Day 3 to 6 – seated on a chair Breathing exercises (as above)
– walking Walking
On day 3, patient starts moving on their own
within the hospital room and the corridor following
the recommendation of taking as frequent walks as
possible.
Coordination exercises
Assisted breathing exercises
Through the movement of upper and lower
extremities (without lifting the arms beyond 900
and abducting them sideways).
Each day the intensity of exercises and the number of repetitions was increased, adjusting it to the patient’s individual needs, capacity and
condition (that is cardio-pulmonary function).
IC: Intensive Care Unit.
4 M. RATAJSKA ET AL.

Figure 1. Relaxing the scalene muscles and the lateral part of cervical fascia – cross technique.

Figure 2. Relaxing the scalene muscles and the lateral part of cervical fascia laterally – “hook – pull” technique.

2. Relaxing the scalene muscles and the lateral part of cervical 11. Relaxing the lower part of rib cage. Both hands simultan-
fascia laterally, “hook-pull” technique (Figure 2), eously lift the lower parts of rib cage on both sides of the
3. Relaxing the descending parts of the trapezius muscle lat- body, closing the costal margins to each other (Figure 11),
erally (Figure 3), 12. Relaxing the medium and the lower parts of the rib cage
4. Relaxing the sternocleidomastoid muscle, cross technique and the intercostal muscles laterally (Figure 12),
(Figure 4), 13. Relaxing the proximal attachments of the rectus abdominis
5. Relaxing the infrahyoid muscles caudad. The hand marked muscle and the tissues adjacent to the xiphoid process lat-
with a dot holds the hyoid bone in cephalad position erally (Figure 13),
(Figure 5), 14. Relaxing the internal oblique muscles laterally (Figure 14),
6. Relaxing the suprahyoid muscles medially (Figure 6). 15. Generally relaxing the tissues within the abdominal cavity.
7. Relaxing the pectoralis major muscles and the sterno-cartil- Spread fingers of both hands encompass the tissues on
aginous fascia medially (Figure 7), both sides of the abdomen, lifting them (Figure 15),
8. Relaxing the pectoralis major muscle, cross technique 16. Relaxing the rectus abdominis muscle and abdominal fascia
(Figure 8), caudad (Figure 16).
9. Relaxing the subclavius muscles medially (Figure 9). MFR techniques were completely painless. During the therapy
10. Relaxing the diaphragm. The upper hand “pushes” the cos- the patient might feel “pulling”, “burning,” “decrease of tension,”
tal margin towards the hand placed below (Figure 10), “melting of tension” or releasing restrictions, while the therapist

Figure 3. Relaxing the descending parts of the trapezius muscle laterally.
Figure 4. Relaxing the sternocleidomastoid muscle – cross technique.
MYOFASCIAL RELEASE IN PATIENT AFTER CABG AND OPCAB 5
felt a change in the end-feel as softer and more resilient. The
intervention was performed by a physical therapist certified in
MFR by Carol Manheim.
Between days 1 and 3, the arterial blood pressure was continu-
ously monitored (continuous venous blood pressure, as well as
blood pressure measurement with a cuff every 15-30 min), systolic
heart function (heart rate, HR: min. increase 20; max. increase 40)
and saturation (SaO2:85% – threshold value, need for intubation;
SaO2:89-94% – exercises 5 times per day assisted by a physical
therapist; SaO2:95–100% – exercises 3 times per day, assisted by a
physical therapist).
Research Tools
The subjects were examined three times: at the admission to the
hospital (before the surgery) and on days 4 and 6 after the pro-
cedure. The primary outcomes included changes in breathing dif-
ficulties, physical capacity/mobility, pain intensity and the level of
fatigue after physical exercises. Secondary outcomes were
changes in FEV1 and FVC. The Evaluation has been performed
with the application of:
a. The visual analogue scale (VAS) [21] for self-assessment of: 1)
breathing difficulties: (where: “0” – meant no difficulties and
“10” was the maximum difficulties (oxygen therapy); 2) phys-
ical capacity/mobility (where: “0” – meant walking with
orthopaedic aids and “10” meant complete fitness); 3) pain
intensity (where: “0” meant no pain and “10” meant the
strongest pain that one can imagine);
b. The Borg scale [22] was used to measure the level of fatigue
after physical exercises, where: “7” meant the minimum
fatigue and “19” meant the maximum fatigue (performed on
days 4 and 6 following the surgery).
c. Spirometer with a calculator of the respiration parameters
(Spirometer Micro Plus) was used to measure FEV1 (L/s) and
FVC (L) (a measurement sheet was prepared in accordance to
age, gender and height). Spirometry was performed in
accordance to the recommendations of the European
Respiratory Society [23]. During the assessment, subjects
were in a sitting position with a correct posture and a nose
clip was used. The highest result of three technically satisfac-
tory manoeuvres was noted. The measurements of FVC and
FEV1 were performed during exhalation with maximum force,
until no more air could be expelled while maintaining an
upright posture [23].
The testing was conducted by qualified medical staff.
Statistical analysis
The results were analysed statistically (Statistica 10.0). The
Mann–Whitney U test was used for non-parametric data (VAS:
breathing difficulties, pain, physical capacity and fatigue in the
Borg scale), the Shapiro-Wilk test was used to verify the normal
data distribution (FEV1 and FVC) and the Student t-test for inde-
pendent samples (FEV1 and FVC), the adopted significance level
was p < 0.05.
Results
The self-assessment in relation to pain intensity (VAS) showed a
statistically significant lower pain intensity in GR II compared to
GR I on day 4 (
x ¼ 5.46 vs 6.58) and 6 (
x ¼ 3.05 vs 5.35) after the
surgery. Before the surgery, groups I and II did not differ statistic-
ally with regard to pain intensity (
x ¼ 3.0 vs 3.3) – Table 4.
6 M. RATAJSKA ET AL.

Figure 5. Relaxing the infrahyoid muscles caudad. The hand marked with a dot holds the hyoid bone in cephalad position.

Figure 6. Relaxing the suprahyoid muscles medially. Figure 8. Relaxing the pectoralis major muscle – cross technique.

Figure 7. Relaxing the pectoralis major muscles and the sterno-cartilaginous fascia medially.

Figure 9. Relaxing the subclavius muscles medially.
Figure 10. Relaxing the diaphragm. The upper hand “pushes” the costal margin
towards the hand placed below.
At the self-assessment of the breathing difficulties (VAS), a stat-
istically significant lower intensity of these difficulties was noted
in GR II compared to GR I – on day 6 after the surgery (
x ¼ 4.08
vs 5.63). Groups I and II did not differ statistically with regard to
the self-assessment of the intensity of breathing difficulties before
the surgery (
x ¼ 3.6 vs 3.9) and on day 4 after the surgery
(
x ¼ 5.95 vs 5.75) – Table 4.
In terms of the self-assessment of physical capacity (VAS), GR II
compared to GR I on day 6 following the surgery noted statistic-
ally significant lower fitness limitations (
x ¼ 6.35 vs 5.13). Groups I
and II did not differ statistically with regard to the self-assessment
of the level of physical fitness before the surgery (
x ¼ 6.85 vs
6.23) and on day 4 (
x ¼ 4.88 vs 4.2) following the surgery –
Table 4.
As far as the self-assessment of the level of fatigue during
exercises (Borg scale) is concerned, a statistically significant lower
level of fatigue was observed in GR II – on days 4 (
x ¼ 13.75 vs
16.51) and 6 (
x ¼ 10.08 vs 14.40) after the surgery – Table 4.
Table 5 presents the spirometry measurement of FEV1 (L/s)
and FVC (L), showing the pulmonary function of subjects before
MYOFASCIAL RELEASE IN PATIENT AFTER CABG AND OPCAB 7
Figure 11. Relaxing the lower part of rib cage. Both hands simultaneously lift
the lower parts of rib cage on both sides of the body, closing costal margins to
each other.
the surgery, on day 4 and 6 after the surgery, the change in this
function (decrease: “”; or increase “þ”) between the first examin-
ation before the surgery, on day 6 post-surger, and between days
4 and 6 after the cardiosurgical procedure.
All subjects examined on day 6 following the surgery, showed
a decrease in FEV1 and FVC – Table 5. However, the measure-
ments taken before the surgery and on day 6 in GR II compared
with GR I showed a significantly lower decrease in FEV1 (
x ¼ -0.65
vs -0.9 L/s) and FVC (
x ¼ -0.63 vs -1.33 L). While the change
between days 4 and 6 after the surgery in GR II compared with
GR I showed a significantly greater increase in FEV1 (
x ¼ 0.21 vs
0.11 L/s) and FVC (
x ¼ 0.32 vs 0.12 L) – Table 5.
Discussion
The rehabilitation of patients following CABG and OPCAB surgery
is subject to numerous limitations. Due to the risk of instability or
diastasis of the sternum and the postoperative wound, at an early
stage following the surgical intervention patients are routinely
not allowed to: lie in supine, side-lying positions, move the
8 M. RATAJSKA ET AL.
Figure 12. Relaxing the medium and the lower parts of rib cage and the intercostal muscles laterally.
Figure 13. Relaxing proximal attachments of the rectus abdominis muscle and
the tissues adjacent to the xiphoid process laterally.
glenohumeral joint, lifting, bracing, while bilateral movements of
the upper extremities are allowed only within a pain-free range of
motion [5,24]. It should be noted that pain in the area of surgery
making the patient limit the aforementioned activities might even
last up to 12 months [25]. Looking from the anatomy trains per-
spective, rehabilitation excludes myofascial structures of the lat-
eral lines and the superficial front line. As a result, the lateral line
transferring the imbalance between the left and the right side of
the body may cause the chest to migrate, as well as limit the
shoulder girdle mobility [18,20]. Additionally, due to sternal pain,
the mobility of cervical region also becomes restricted, forcing
the patient into a kyphotic posture, which may lead to further
dysfunctions within the myofascial system [26]. The aforemen-
tioned changes have a negative impact on respiration, which is
supported by the fact that patients following the two surgical
interventions: CABG and OPCAB, change their breathing pattern
from abdominal to thoracic or upper thoracic [27]. In our previous
studies we have shown that therapy oriented on the improve-
ment in chest mobility (Manheim MFR – carried out in an identi-
cal mode to the one described in the present study) benefits the
patients’ respiration, which translates directly into the improve-
ment in everyday functioning [19]. It should be noted that in MFR
one works with fascial structures, therefore, there is no direct
influence on bone structures, which is contraindicated in the early
postoperative period after cardiac surgeries. At the same time,
thanks to the application of MFR, it is possible to eliminate tissue
restrictions without the aid of placing the extremities in extreme
positions (e.g., abducting the arm in order to obtain the max-
imum distance between the attachments of the pectoralis major),
which, as mentioned earlier, is contraindicated in this group of
patients. MFR techniques are comfortable and safe for patients.
Because of that, the Carol Manheim technique of the myofascial
release applied to the upper chest before and after respiration
therapy or postural drainage in patients after CABG may be an
important contribution to their rehabilitation process, which
seems to be supported by this study.
Based on our own research, as well as the research of other
authors, it may be stated that CABG and OPCAB surgical interven-
tions entail the deterioration of pulmonary function, which mani-
fests itself in disrupted ventilation of the restrictive type in the
first days after the surgery [27–30]. Regardless of the group, all
subjects on day 6 after the surgery presented a decrease in FEV1
and FVC. However, in GR II, where the MFR techniques were
applied, the postoperative decrease in FEV1 (comparing the
period before the surgery and on day 6 after the surgery) was sig-
nificantly lower. Moreover, in the period between days 4 and 6
after the surgery, subjects from GR II, compared to GR I, showed a

Figure 14. Relaxing the internal oblique muscles laterally.
Figure 15. General relaxing the tissues within the abdominal cavity. Spread fin-
gers of both hands encompass the tissues on both sides of the abdomen, lift-
ing them.
statistically significant increase in FEV1 and FVC. It may be stated
that the observed difference might have been caused by the
introduction of the MFR technique in GR II on day 3 after
the surgery.
To the best of the authors’ knowledge, it is the first study
measuring the impact of the MFR technique on pulmonary
MYOFASCIAL RELEASE IN PATIENT AFTER CABG AND OPCAB 9
Figure 16. Relaxing the rectus abdominis muscle and abdominal fascia caudad.
function in patients following CABG surgery in the early postoper-
ative stage. The suggested protocol based on the MFR techniques
is consistent with the trend in other areas of research aimed at
finding efficient physical therapy techniques after CABG and
OPCAB surgeries [30,31].
In our own research, regardless of the postoperative rehabilita-
tion protocol, in both groups on day 6 following the surgery, the
measurements of FVC and FEV1 were lower compared to the
10 M. RATAJSKA ET AL.

Table 4. Self-assessment of pain intensity, breathing difficulties, level of physical fitness and fatigue.
GR I (N ¼ 40) GR II (N ¼ 40)
Coefficient Evaluation (
x ;SD) (
x ;SD) p
Pain intensity (VAS) Before surgery 3.30 ± 0.71 3.00 ± 1.43 0.0769
On day 4 6.58±0.68 5.46±1.15 0.0150
On day 6 5.35±0.66 3.05±1.50 0.0320
Breathing difficulties (VAS) Before surgery 3.90 ± 1.15 3.60 ± 2.11 0.0560
On day 4 5.75 ± 0.98 5.95 ± 1.26 0.0567
On day 6 5.63±0.98 4.08±1.03 0.0034
Physical fitness (VAS) Before surgery 6.23 ± 1.44 6.85 ± 1.53 0.3420
On day 4 4.20 ± 1.26 4.88 ± 1.15 0.7810
On day 6 5.13±1.09 6.35±1.31 0.0070
Level of fatigue during exercises (Borg scale) On day 4 16.51±1.72 13.75±1.36 0.0005
On day 6 14.40±1.41 10.08±0.95 0.0001
Results of statistically significant difference were underlined at p < 0.05 (U Mann-Whitney Test).

x : arithmetic mean; SD: standard deviation.

Table 5. Results of spirometry tests FEV1 and FVC.

Respiration Capacity (
x ; SD)
FEV 1 (L/s) FVC (L)
Group I Group II Group I Group II
Evaluation (N 5 40) (N 5 40) p (N 5 40) (N 5 40) p
Before surgery 2.08 ± 0.51 2.34 ± 0.82 0.578 2.63 ± 0.73 3.13 ± 0.91 0.160
On day 4 0.80±0.23 1.49±0.62 0.000 1.19±0.42 2.18±0.73 0.000
On day 6 0.90±0.26 1.70±0.66 0.000 1.30±0.42 2.50±0.73 0.000
Before surgery vs day 6 (decrease: “” / increase t: “þ”) -0.9±0.35 -0.65±0.33 0.012 -1.33±0.37 -0.63±0.43 0.001
Day 4 vs day 6 (decrease: “” / increase t: “þ”) 10.11±0.05 10.21±0.12 0.001 10.12±0.04 10.32±0.23 0.0267
Results of statistically significant difference were underlined at p < 0.05 (T-Student Test).

x : arithmetic mean; SD: standard deviation.

initial results. It is consistent with the reports of other authors
[27,28,32,33]. A valuable observation would be the assessment of
the impact of MFR on pulmonary function in a period time-wise
distant from the surgery, checking how long a period of time is
needed for FVC and FEV1 to regain their initial values. In this
regard, there is also no consensus in the literature. Individual
studies suggest that it is 30 days after the surgery [32,33], while
others observe no regaining of initial values after 3-4 months
[12,13,34] or even a year [10] after the surgery.
The literature is still looking for efficient therapies, which might
be helpful in fighting common complaints after CABG and
OPCAB, i.e., sternal pain, breathing difficulties, general weakening,
problems with badly healing wounds, pain in the thoracic and
cervical spine, arm pain or restrictions in physical fitness [5]. Apart
from the traditional protocol, individual studies point at the bene-
ficial effects of additional therapies, i.e., music therapy [35], oste-
opathy [36], massage [37–40], foot reflexology [41] or reiki
therapy [42]. To the best of the authors’ knowledge this study is
the first attempt at the evaluation of the efficacy of the Carol
Manheim MFR technique on the subjectively assessed pain issues,
breathing difficulties, physical fitness and fatigue. In GR II, the
additionally provided MFR techniques, statistically better signifi-
cant results were recorded in comparison to GR I with regard to
the self-assessment of pain intensity on days 4 and 6 after the
surgery, breathing difficulties on day 6 after the operation, phys-
ical fitness on day 6 and the level of fatigue on days 4 and 6 after
the surgical intervention. These positive changes noted in GR II
indicate a correlation with the implementation of MFR techniques
on day 3 following the surgery. Similar conclusions were reached
by Bauer et al. [39] and Cutshall et al. [40], who studied patients
after CABG surgery, between days 2 and 5 after the surgery, using
a massage including i.a. myofascial and connective tissue release
techniques. Compared to the control group which was following
conventional rehabilitation, in patients receiving supplementary
massage, the authors observed both statistically and clinically sig-
nificant decreases in pain, anxiety and tension scores.
It should be emphasised that acute postoperative pain in the
first week after the surgery was found as a significant risk factor
of persistent postoperative pain, which may last even up to 24
months after the surgery [43], doubtlessly lowering patients’ qual-
ity of life. Moreover, pain may adversely affect the post-surgery
wound healing [44]. The above results provide even more support
to the need of implementing both efficient and safe forms of
therapy decreasing pain in patients during the early postoperative
period after CABG and OPCAB. Based on the results of our studies,
the Carol Manheim MFR techniques can be a recommended form
of therapy in this group of patients.
To sum up, based on the performed study, a conclusion may
be drawn that MFR techniques may constitute a valuable supple-
ment for a conventional cardiosurgical rehabilitation, enhancing
its outcomes in patients after CABG and OPCAB surgeries. Their
safety, painlessness and comfort fit into the needs and limitations
of this group of patients. Despite the increasing popularity of the
MFR techniques in PT/clinical practice, their effectiveness has not
been properly verified in research studies. There is a need for reli-
able and well-conducted research studies evaluating the effective-
ness of MFR techniques. It is worth emphasising that the present
report fits into this need and pertains to the pioneering, on a
national level, implementation of MFR techniques in the rehabili-
tation of patients during the first phase after coronary artery
revascularisation.
Conclusions
1. MFR techniques might be a valuable supplementation for a
conventional cardiac rehabilitation, enhancing its outcomes
in patients after CABG and OPCAB surgeries during the early
postoperative period.

2. The implementation of MFR techniques contributes to the [13]
improvement of pulmonary function (FEV1 and FVC) in
patients after CABG and OPCAB.
3. The adoption of the MFR techniques contributes to lessening [14]
breathing difficulties, pain intensity, fatigue and improving
physical fitness – in self-assessment (VAS) of patients after [15]
CABG and OPCAB.
4. There are still no reliable research studies evaluating the
influence of the MFR techniques as an alternative form of
physical therapy. [16]
Disclosure statement
[17]
The authors report no conflicts of interest.
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