INTRODUCTION:

Mastectomy is not always the preferred course of therapy and is typically reserved for tumors that are large relative to the size of the breast or that have recurred. Breast cancer has been a major issue of discussion over the past few decades, and the public is much more aware of it than they were previously¹. Many reconstructive techniques and patterns have gained popularity after skin-sparing mastectomy was recognized as an ethically sound choice for breast cancer patients. Reconstructive surgeons face specific problems when dealing with certain patient groupings. Patients who are obese and have autologous flap reconstruction are more likely to experience delayed wound healing, fat necrosis, and superficial skin loss. Complicated reconstructive operations are more likely to be declined by older individuals. Prolonged surgical periods may be outright contraindicated for patients with serious medical comorbidities². Globally, breast cancer is the primary cause of cancer-related deaths among women. Over the past few decades, its surgical method has become less and less mutilating. But overall, there have been a lot more breast reconstructions recently. In the modern era, optimal individualization of breast reconstruction involves first taking into account the patient's condition and preferences, as well as the oncological aspects of the tumor, neo-/adjuvant treatment, and genetic predisposition. Additionally, the timing of the reconstruction—immediate versus delayed—must be taken into account³. Prophylactic mastectomy can dramatically lower the incidence of breast cancer in women who have a strong family history of the disease. The need to weigh the advantages and disadvantages of early identification and preventive interventions for women at high risk of breast cancer has increased with the development of more sophisticated methods for doing so, such as genetic testing for BRCA1 and BRCA2 mutations⁴. It has been more than 20 years since concerns were raised regarding the overuse of mastectomy in patients with breast cancer. Some have attempted to quantify quality using the rates of breast-conserving surgery. Concerns about women with breast cancer receiving excessive mastectomy treatments still exist, even despite a notable rise in BCS. Despite their surgeons' strong support for BCS, many studies indicate that many women who have mastectomy either choose mastectomy or are contraindicated for adjuvant radiation therapy or BCS⁵. There are important psychological and sexual ramifications to losing a breast following a mastectomy. Even while an external breast prosthesis can conceal breast loss from others, a woman's body image is never altered by it, and it doesn't always help her deal with the sense of abnormality⁶. Currently, the primary goal of surgical treatment for breast cancer is local control, which is also regarded as a component of systemic therapy. Breast-conserving surgery serves as the cornerstone of this approach. However, depending on the location or size of the lesion and the existence of a large intraductal lesion, almost one-third of females with breast cancer still have mastectomy⁷. Cancer arises when the immune system malfunctions or when the quantity of cells created exceeds the immune system's capacity to eradicate. Under some circumstances, such as an unfavorable environment (from radiation, chemicals, etc.), a bad diet (which creates an unhealthy cell environment), individuals who are genetically predisposed to mutations, and elderly individuals (over 80), the rate of DNA and RNA mutations can be excessively high⁸. Patients with early-stage breast cancer are typically offered two main treatment options: either mastectomy and axillary staging, which typically eliminates the need for additional radiation therapy, or breast conserving surgery (BCS) and axillary staging, followed by adjuvant radiotherapy⁹. Breast tissue offers an infertile environment for the survival and growth of TB bacilli, which contributes to its remarkable resistance to tuberculosis. This is one reason why breast TB is an uncommon symptom. Axillary involvement has been observed in as many as 75% of instances with tuberculous mastitis, suggesting that retrograde lymphatic involvement is the mechanism by which breast TB most frequently results from illness transmission from elsewhere¹⁰. Typically, women who are of reproductive age contract tuberculosis. It is most commonly associated with nursing mothers and quite rare in older men. The way it manifests clinically varies. Rarely do constitutional symptoms like fever, weight loss, sweats at night, or a general decline in health occur. Most patients have a positive skin test result for tuberculin¹¹.

Table 01. NPRS (numerical pain rating scale)

NPRS Scale	Score
On activity	9/10
At rest	6/10

Table 02. IMMT (individual manual muscle testing)

Muscles around the breast which are affected	Score
1. Platysma	3/5
2. Trapezius	3/5
3. Deltoid	3/5
4. Pectoralis major	2/5
5. Pectoralis minor	2/5
6. Subclavius	3/5
7. Serratus anterior	2/5
8. Rhomboids	3/5
9. Latissimus dorsi	2/5
10. Intercostal muslces	2/5
11. External oblique	3/5
12. Rectus abdominis	3/5

Table 03. Chest Expansion

Factor	Effect on Chest Expansion	Expansion
Multidrug-resistant TB (MDR-TB)	Lung fibrosis and scarring may restrict lung expansion.	Reduced (1-2 cm)
Chronic Anemia	Fatigue and weakness of respiratory muscles reduce effort.	Reduced (1-2 cm)
Cachexia (Severe Weight Loss)	Muscle wasting, including respiratory muscles, impairs expansion.	Severely Reduced (1-2 cm)
Pancytopenia and Bone Marrow Suppression	Lower oxygen-carrying capacity weakens muscles, reducing lung function.	Reduced (1-2 cm)
Generalized Weakness (Upper and Lower Extremities)	Decreased physical capacity limits chest expansion.	Reduced (1-2 cm)
Lymphadenopathy (Cervical and Axillary)	Discomfort or stiffness around the thoracic area limits expansion.	Slight Reduction
Long-Term Antitubercular Therapy (ATT)	Possible drug toxicity affecting muscle function.	Reduced (1-2 cm)
Diabetes Mellitus (Poor Glycemic Control)	Diabetic neuropathy may affect respiratory muscles.	Mild Reduction (2-3 cm)
Hypertension (On Treatment)	Minimal direct impact unless heart failure is present.	Normal (4-6 cm)

Table 04. Modified medical research council (MMRC) grades for dyspnea

Dyspnea grades	Pre- treatment	Post- treatment
Grades	3/5	0/5

Table 05. 6-Minute Walk Tests Pre- and Post-Treatment Findings

Parameter	Pre-Treatment Findings	Post-Treatment Findings
Distance Walked	Significantly reduced (200-300 meters); fatigue and weakness evident.	Increased distance (350-450 meters); improved endurance observed.
Dyspnea (Borg Scale)	Higher score (≥ 3), indicating moderate to severe breathlessness	Lower score (1-2), reflecting reduced breathlessness during exertion
Fatigue	Frequent stops due to fatigue and exhaustion.	Fewer or no rest breaks; improved stamina and reduced fatigue.
Heart Rate (Post-Test)	Marked increase, indicating cardiovascular stress.	More stable heart rate; improved cardiovascular efficiency.
Oxygen Saturation (Post-Test)	Possible drop (e.g., below 90%).	More stable saturation, closer to baseline levels (>90%).
Perceived Exertion (RPE)	High RPE score (15-17), indicating significant effort and exhaustion	Lower RPE score (11-13), indicating moderate exertion post-rehabilitation
Resting Time	Several rests needed; reduced tolerance for continuous walking.	Fewer or no rests; improved endurance and functional capacity.

Table 06. Timed up and go test (TUG)

Parameter	Pre-Treatment Findings	Post-Treatment Findings
Time to Complete (seconds)
Balance	Difficulty maintaining balance while standing or turning; may need support.	Improved balance with more stable standing and turning movements.
Gait	Unsteady, slow, or shuffling gait due to weakness, fatigue, and dyspnea.	Improved gait pattern with better control and less fatigue.
Ability to Rise from Chair	Requires arm support or multiple attempts due to leg weakness.	Able to stand up smoothly with minimal or no support from arms.
Fatigue	Significant fatigue, may need to stop during the test or slow down.	Reduced fatigue, completing the test without the need for rest.
Perceived Effort	High perceived effort, showing signs of discomfort or exertion.	Lower perceived effort, with the patient feeling more comfortable during the test.

Table 07. Physiotherapy interventions in a patient with multidrug-resistant tuberculosis

Goals	Interventions	Dosage
1. Patient education	To aware a patient and their family about their condition and how physiotherapy helps them in their condition.	Patient and their family were educated about the importance of physiotherapy
2. To improve lung expansion and oxygenation	Deep breathing exercises and incentive spirometry	10reps x 1 set
3. To improve and maintain lung capacity	Thoracic expansion exercises	10reps x 1 set
4. To facilitate the clearance of secreations from the lungs	Autogenic drainage	3reps
5. To control dyspnea and improve ventilation efficiency	Deep breathing, sitting upright position	10reps x 1 set
6. To improve daily activities like moving in bed, sitting and standing etc.	Bed mobility and transfers, bed side sitting	10 min
7. To rebuild muscle strength and improve endurance	Gradual strengthening exercises	10reps x 1 set
8. To improve proprioception and enhance stability during standing or walking	Balance and coordination exercises	10reps x 1 set
9. To enhance balance and endurance for walking without falls	Gait training	-
10. To prevent joint stiffness and contractures and maintain joint health	Gentle range of motion exercises	10reps x 1 set
11. To maintain and improve joint flexibility and reduce muscle tightness	Gradual stretching exercises	10reps x 1 set
12. To alleviate discomfort by reduing pressure on sensitive areas and promote proper alignment to prevent complications like pressure ulcers	Positioning	-
13. To improve cardiovascular health and promote circulation	Low impact cardiovascular exercises	10reps x 1 set
14. To provide a motivating and immersive environment for rehabilitation and improve adherence to exercise	Virtual reality (VR) assisted therapy	-
15. To enhance muscle strength and reduce strain on the cardiovascular system	Blood flow restriction (BFR) training	-

Figure 01: X-ray finding - Opacification is seen in the middle and lower left lobes, and bronchovesicular margins are diminished.

DISCUSSION:

Physiotherapy with a multimodal approach was necessary for the management of a patient with Multidrug-Resistant Tuberculosis (MDR TB) and related comorbidities. Developing and executing the rehabilitation program required careful attention due to the patient's complex clinical presentation, which included severe pancytopenia, anemia, widespread weakness, and related comorbidities. Breathing problems, tiredness management, and increasing general functional capacity were the main priorities¹².

The goals of respiratory physiotherapy and breathing exercises were to improve lung function and avoid problems brought on by respiratory impairment. Improved lung expansion, oxygenation, and secretion clearance were made possible by strategies like diaphragmatic breathing, incentive spirometry, and airway clearing techniques. Given the patient's impaired respiratory condition and increased risk of MDR TB infections, these therapies were essential¹³.

The rehabilitation strategy placed a strong emphasis on fatigue management and energy conservation techniques. Through the implementation of task breaking strategies and regular rest periods, the patient's fatigue was effectively managed while still enabling them to participate in everyday activities. The patient's deconditioned state and restricted tolerance for severe physical exercise were taken into account while designing the progressive strengthening program, which aimed to restore muscle strength and endurance¹⁴.

The goal of mobilization and functional training was to increase the patient's freedom and mobility. The goal of bed mobility and transfer training was to increase the patient's capacity to carry out necessary daily tasks. Given the patient's general weakness and balance problems, gait training, balance, and coordination exercises were critical to restoring safe walking abilities and lowering the risk of falls¹⁵.

To keep flexibility and avoid stiffness, joint and soft tissue mobility therapies were used, such as stretching and mild range-of-motion exercises. These treatments were especially crucial for reducing the negative consequences of extended immobility and increasing mobility in general¹⁶.

Manual lymphatic drainage techniques were utilized to decrease edema and improve lymphatic circulation due to the existence of localized swelling resulting from involvement of lymph nodes. This strategy was developed to target particular MDR TB-affected areas¹⁷.

Pain relief techniques, such as proper positioning, were applied to reduce discomfort and improve the patient's quality of life. In order to promote the patient's mental health, psychological care and counseling were also essential. These services focused on teaching patients stress-reduction strategies and illness management¹⁸.

CONCLUSION:

To effectively address a wide range of complicated needs resulting from her disease, the physiotherapy intervention for this patient with multidrug-resistant tuberculosis (MDR TB) and its comorbidities was carefully planned. The all-inclusive strategy was designed to improve her total functional ability and quality of life in addition to treating her severe respiratory conditions.

Deep breathing, incentive spirometry, and airway clearing procedures are among the respiratory physiotherapy approaches that are effective in improving lung function and reducing problems, including atelectasis and respiratory infections. As her respiratory condition deteriorated, these measures were crucial in maximizing lung expansion and improving the patient's ability to remove secretions.

Energy-saving techniques were especially important because of the patient's extreme weakness and weariness. Through the implementation of task division strategies, frequent rest intervals, and a graduated approach to activity, the patient was able to engage in everyday activities without experiencing undue weariness. This approach enabled her in gradually regain strength and endurance without aggravating her condition, in addition to helping her manage her energy levels.

The patient's independence and mobility were much enhanced by mobilization and functional training. While gait training and balance exercises addressed her fall risk and enhanced her walking skills, bed mobility and transfer training made it easier for her to carry out necessary daily tasks. To improve her safety and functional capacity, these therapies were customized to meet her unique needs, taking into account her general frailty and balance problems.

In general, the customized physical therapy approaches proved effective in tackling the complex issues brought about by the patient's state. A higher quality of life and greater functional outcomes were attained by the patient as a result of the program's flexibility and attention to their specific needs. Together with addressing psychological issues, the holistic approach promoted physical healing, making the rehabilitation process more encouraging and successful.

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Received on 06.04.2025 Revised on 23.04.2025

Accepted on 09.05.2025 Published on 15.05.2025

Available online from May 17, 2025

Research J. Science and Tech. 2025; 17(2):133-138.

DOI: 10.52711/2349-2988.2025.00019

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