An Advanced Comprehensive Physiotherapy Management for Empyema Thoracis and Scoliosis: A Case Report

Tuberculous empyema is caused by Mycobacterium tuberculosis infection of the pleural cavity, resulting in purulent pleural fluid formation. Tuberculous empyema most commonly develops in patients with tuberculous pleuritis treated with artificial pneumothorax. However, it can also develop in patients with chronic tuberculous pleuritis, usually in patients with pulmonary tuberculosis treated with antituberculous chemotherapy. Scoliosis is a three-dimensional spine deformity caused by several factors, including genetic susceptibility, anterior and posterior spinal development imbalance, and connective tissue abnormalities (skeletal muscle and nerves). Although surgery is the most talked-about treatment option, there is high-quality evidence suggesting the use of conservative therapy in the management of scoliosis. A systematic rehabilitation plan with a variety of approaches was developed, and it was found to be a highly successful protocol for treating the patient’s empyema and scoliosis.


Introduction
A common pulmonary consequence of tuberculosis in the pre-chemotherapy period was tuberculous empyema. It was either caused by progressive pulmonary tuberculosis or any surgical intervention. Even though its incidence has decreased, it accounts for up to 6% of total empyema cases. In more severe cases of tuberculous, empyema results from cavitation into the pleural space or brutal invasion of the parenchymal focus, contrary to pleural effusion caused by tuberculous pleurisy, wherein hypersensitivity plays an important role [1].
Tuberculous empyema is caused by Mycobacterium tuberculosis infection of the pleural cavity, resulting in purulent pleural fluid formation. Tuberculous empyema most commonly develops in patients with tuberculous pleuritis treated with artificial pneumothorax. However, it can also develop in patients with chronic tuberculous pleuritis, usually with trapped lungs, or patients with pulmonary tuberculosis treated with antituberculous chemotherapy [2]. Tuberculous empyema is more common in middle-aged adults. Patients frequently have pulmonary or pleural tuberculosis for more than 10 years before the empyema is discovered [3]. Clinically, symptomatic people with a chronic or subacute clinical picture are characterized by fever, nocturnal sweats, weight loss, and an elevated erythrocyte sedimentation rate. The most common radiological symptom is a pleural-based density. Chest tomography frequently reveals an enlarged rib cage, loculated pleural effusion, and a thick, fibrocalcific pleura. The existence of air-fluid levels verifies the presence of a bronchopleural fistula [4].
Scoliosis roughly affects 3% of the population, mainly females. It is a three-dimensional spine deformity in a three-dimensional plane due to genetics, improper development of the anterior and posterior spine, and connective tissue abnormalities of skeletal muscle and nerves. Surgery is a widely discussed treatment option for scoliosis, but some studies suggest conservative management helps manage scoliosis [5].

Case Presentation
Relatives brought a 35-year-old male, a mason by occupation, with the chief complaints of cough with mucoid expectoration, fever (on and off), low grade and intermittent, loss of appetite, and weight loss for the last two months. He had been experiencing breathlessness for one week. There was no history of hemoptysis or Koch's contact, and he was an alcoholic for 10 years, 100 mL per day. He stopped consuming alcohol for three months. The patient went to a local hospital two months back. On investigations, a chest X-ray revealed pleural effusion. The physician inserted an intercostal drain (ICD) and drained 2 L of strawcolored fluid. The patient started CAT-I DOTS (Category 1 Directly Observed Therapy). Category 1 treatment was given for the intensive phase, i.e., the first two months. After one month, the patient went for a followup when a repeat chest X-ray showed pleural effusion. The physician performed diagnostic tapping and placed an ICD, removing it after draining 200 mL of fluid. Table 1 presents the chronology of the events.   Table 2 shows the pre-rehabilitation assessment.   Figure 1 and Figure 2 show the radiological findings of the patient.

Therapeutic intervention
Physiotherapy management began as soon as the patient's ICD tube was removed, with the goal of improving the patient's ventilation and exercise tolerance capacity, clearing the airways, reducing the effort of breathing, and promoting relaxation. It would enable the patient to carry out daily activities without experiencing weariness or discomfort. The Frequency, Intensity, Time, and Type (FITT) principle guided the design of the physiotherapy interventions. Table 3 shows the treatment administered with goals. Figure 3 shows the patient doing thoracic expansion exercises.  To enhance exercise tolerance

Goals
The therapist designed an incremental physical treatment regimen, starting with bedside sitting and progressing to bedside mobility exercises like walking for at least 10 minutes or to the patient's tolerance. The therapist then gradually advanced the treatment based on the patient's responsiveness and perceived exertion rate. The regimen was followed for four to seven days per week for 20-60 minutes until the heart rate reached 50-90% of its maximum

Orthotic management
To correct and further decline the progress of deformity Milwaukee brace for six hours during the acute phase

Follow-up and outcomes
The therapist planned the physiotherapy program for two weeks, including four weekly sessions in the hospital inpatient setting. After two weeks, when the patient's exercise tolerance capacity had improved, the patient was discharged with a well-explained home exercise routine and scheduled for a two-week followup. Table 4 shows the comparison between pre and post-rehabilitation assessments.

Discussion
In medical wards, empyema is a prevalent ailment. The accumulation of pus within the chest cavity leads to empyema. Pneumonia is the most prevalent cause of empyema. In the care of such individuals, physiotherapy or cardiorespiratory physiotherapy intervention is critical. An overall goal of a physiotherapy program is to use cutting-edge, economically viable therapeutic modalities, minimize patient dependence, enhance residual function, lower the likelihood of rehospitalization, and enhance the quality of life. Breathing exercises, particularly segmental breathing exercises, are a straightforward, low-cost, and simpleto-implement therapy [6].
Scoliosis treatment should focus on the functional and physiological difficulties it causes. Scoliosis has no acute symptoms or signals that necessitate surgery. It is critical to slow down the curve's evolution and avoid the emergence of inappropriate postural habits. Early intervention, such as exercises and posture retraining, can help achieve this [7]. Sarkar et al. discovered that in restricted lung disorders such as empyema, breathing exercises such as segmental breathing are particularly helpful and can enhance lung expansion [8].
Controlling infection, draining the purulent fluid, and eradicating the sac to avoid chronicity and reexpansion of the damaged lung to restore function are the goals of pleural empyema therapy. The patient's clinical status, the extent of the effusion, and imaging data determine the treatment. Antibiotics, recurring thoracentesis, tube thoracostomy, fibrinolytic agent therapy, decortication, and video-assisted thoracoscopic surgery (VATS) are all options for treating empyema. Some experts advocate antibiotics in conjunction with tube thoracostomy and intrapleural fibrinolytic medications as the best treatment for empyema. Others argue for early surgical intervention such as VATS [9].

Conclusions
This study demonstrates that physiotherapy combined with medical care and drainage in inpatients with pleural effusion and scoliosis is associated with a shorter hospital stay and a better recovery. For patients with pleural effusion, adding physiotherapy based on mobilizations, deep breathing exercises, and incentive spirometry to the conventional treatment is possible and can improve pulmonary function and quality of life. In individuals with pleural effusion, there is evidence that physical therapy treatment reduces the severity of this illness with radiographic improvement. This study also demonstrates that orthotic management and physiotherapy can be used to treat scoliosis with clinically evident results.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.