734 - Therapy Modifications to Promote Activity Tolerance in a Patient with Subclavian Steal Syndrome: A Case Report

Case Diagnosis: Subclavian steal syndrome

Case Description: A 73-year-old man with intractable back pain secondary to osteomyelitis underwent cardiac risk stratification prior to thoracic fusion. Doppler studies were remarkable for retrograde flow in the right vertebral artery; angiography revealed bilateral high grade subclavian artery stenosis with near-complete right sided occlusion. Vascular intervention was deferred as initiation of antiplatelet therapy would delay spinal surgery. Postoperatively, the patient’s participation in inpatient rehabilitation was limited by severe dyspnea, diaphoresis, and near-syncope when using the upper extremities, which precluded conventional therapy approaches. A rehabilitation program incorporating self-identification of triggering activities, environmental adaptations, and exercise modifications was undertaken to improve activity tolerance while minimizing subclavian steal symptoms. Using this approach, the patient made measurable improvements in functional activity as reflected in the AM-PAC “6-Clicks” score and CMS CARE Item Set inventory. He also reported subjective improvements in self-awareness of triggering activities and perceived safety at discharge.

Discussions: Subclavian steal results from a low-pressure state of the distal subclavian artery causing retrograde flow of the posterior cerebral circulation. While the incidence of subclavian steal is approximately 2.5%, only 18% of patients have syncopal symptoms. These symptoms are classically exacerbated by exercising the affected extremity, which may include reaching, strength training, and hand pedaling (a common substitute for upright cardiovascular exercise in patients struggling with orthostatic hypotension during rehabilitation.) To our knowledge, this is the first case documenting the unique challenges imposed by subclavian steal in the inpatient rehabilitation setting, as well as providing an outline for physical and occupational therapy modifications to improve performance in this unique patient population.

Conclusions: Subclavian steal syndrome imposes limitations on the use of the upper extremities during inpatient rehabilitation; a treatment approach targeting symptom trigger identification and environmental modifications is effective at promoting functional improvement even when definitive treatment of subclavian stenosis is not feasible.